Surreal illustration of a dancer's ankle with gears representing the complexity of dance injuries.

Dancing Without Pain: Treating Ankle Impingement and Tendon Issues in Dancers

Theo Raines in Health & Wellness December 2025 • 4 min read.

"A Comprehensive Guide to Understanding, Treating, and Preventing Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus (FHL) Tendinopathy in Dancers"

For dancers, the extreme positions required for pointe work and relevé can place significant stress on the ankle, leading to conditions like posterior ankle impingement syndrome (PAIS) and flexor hallucis longus tendinopathy (FHL), also known as "dancer's tendinitis." These conditions, whether occurring alone or together, can significantly impact a dancer's ability to perform.

A recent systematic review sought to evaluate the effectiveness of both conservative and surgical treatments for PAIS and FHL in dancers, while also exploring the historical context of dance medicine publications on this subject. This comprehensive analysis provides valuable insights for dancers, dance medicine professionals, and anyone involved in the care of these athletes.

This article breaks down the findings of that review, offering a clear understanding of the available treatment options, their success rates, and the factors that influence a dancer's return to pain-free performance. We'll also delve into the history of how these conditions have been understood and treated in the dance world.

Understanding PAIS and FHL in Dancers: Why Are Dancers at Risk?

Surreal illustration of a dancer's ankle with gears representing the complexity of dance injuries.

Dancing demands extreme plantar flexion (pointing the toes), pushing the ankle joint to its limit. This repetitive stress, combined with the unique biomechanics of dance, makes dancers particularly susceptible to PAIS and FHL. Unlike other sports where plantar flexion might be sudden or brief, dance involves sustained, controlled, and weight-bearing plantar flexion.

Here's why these factors contribute to ankle problems:

Repetitive Peak Stress: The extreme positions create repeated high stress on the bony structures at the back of the ankle.
Weight-Bearing: In relevé and pointe, the ankle joint is fully weight-bearing at its end range of motion, maximizing the force transmitted through the bones.
Unique Muscle Use: The calf muscles (triceps surae) constantly pull the heel upwards, contributing to impingement.

While PAIS and FHL can occur separately, they often coexist. FHL tendinopathy, affecting the tendon that runs along the back of the ankle and under the foot to control the big toe, is frequently seen alongside PAIS. This combination is often referred to as "dancer's tendinitis."

Moving Forward: Research and Improved Treatment Strategies

The systematic review highlights the need for more high-quality research to refine treatment strategies for PAIS and FHL in dancers. Existing studies are limited by their retrospective nature and lack of standardized outcome measures specific to dance.

Future research should focus on:

<ul><li>Prospective Studies: Designing studies that follow dancers over time, tracking their progress with specific, dance-related outcome scores.</li><li>Comparative Trials: Comparing different conservative and surgical treatment approaches to determine which are most effective.</li><li>Individualized Treatment: Considering factors like dance style, level of participation, and specific anatomical variations to tailor treatment plans.</li></ul>

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.12678/1089-313x.22.1.19, Alternate LINK

Title: Results Of Treatment Of Posterior Ankle Impingement Syndrome And Flexor Hallucis Longus Tendinopathy In Dancers: A Systematic Review

Subject: General Medicine

Journal: Journal of Dance Medicine & Science

Publisher: J. Michael Ryan Publishing

Authors: A. B. M. Boni Rietveld, F. M. T. Hagemans, S. Haitjema, T. Vissers, R. G. H. H. Nelissen

Published: 2018-03-15

Everything You Need To Know

What are the main ankle conditions that affect dancers?

The conditions mentioned, namely Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL), are common in dancers due to the extreme and repetitive stresses placed on their ankles. These include extreme plantar flexion, weight-bearing at the end range of motion, and unique muscle use. PAIS involves the impingement of soft tissues or bony structures at the back of the ankle, while FHL tendinopathy affects the tendon that controls the big toe. The combination of these two is often referred to as "dancer's tendinitis".

Why are dancers more prone to ankle problems like Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL)?

Dancers are particularly at risk of Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL) because of the biomechanics of dance. The required plantar flexion, especially in pointe work and relevé, forces the ankle joint to its limits, leading to repeated high stress on the bony structures. Furthermore, the constant use of calf muscles (triceps surae) contributes to impingement, while weight-bearing in these positions amplifies the forces through the ankle.

Why is it important to understand Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL) in the context of dance?

The importance of understanding Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL) lies in its direct impact on a dancer's ability to perform. These conditions cause ankle pain, and limit the dancer's range of motion. This affects their ability to execute movements correctly and, thus, their overall performance. Effective treatment and prevention strategies are essential to allow dancers to continue performing pain-free.

What are the current treatment strategies for Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL)?

Current treatments for Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL) include both conservative and surgical options. The success rates and specifics of these treatments, however, are subjects of ongoing research. The article emphasizes the need for more high-quality research to improve and refine these treatment strategies, highlighting that existing studies are limited by their retrospective nature and a lack of dance-specific outcome measures. The primary goal is to return dancers to pain-free performance.

What are the long-term implications of Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL) for a dancer?

The implications of Posterior Ankle Impingement Syndrome (PAIS) and Flexor Hallucis Longus Tendinopathy (FHL) for dancers are significant, potentially leading to career-altering consequences. Understanding these conditions can improve early detection and intervention, and potentially improve a dancer's long-term performance. It is crucial to continue advancing dance medicine knowledge and refining treatment approaches through rigorous research. This will improve the management of PAIS and FHL, and contribute to the overall health and longevity of dancers' careers.