Dancing Without Pain: Treating Ankle Impingement and Tendon Issues in Dancers
"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.
Limited Evidence, Frequent Problems
Foot and ankle injuries are reported as the highest-number injuries among professional and pre-professional dancers, particularly in ballet; ankle sprains are followed by posterior ankle impingement syndrome (PAIS) and flexor hallucis longus (FHL) tendinopathy. A 2018 systematic review found only six publications covering conservative treatment in 33 ankles among 28 dancers: 13 with PAIS and 20 with FHL tendinopathy. The review concluded that this evidence was insufficient for evidence-based treatment recommendations, and most studies did not report dance-specific characteristics such as style or participation level.
Treatment Requires Specialization
The listed clinical sources describe FHL tendinopathy as a dancer-specific ankle problem that can cause pain on push-off during pointe work. They present specialized treatment and rehabilitation as part of the pathway toward a safe return to dance. However, the provided material does not specify a standardized treatment protocol or establish which individual methods are most effective.
Understanding PAIS and FHL in Dancers: Why Are Dancers at Risk?
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.
- 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.
Imaging and Outcomes Remain Complex
A 2025 systematic review reports that posterior ankle impingement caused by an os trigonum has been reported in a high percentage of female ballet dancers, as well as in fast bowlers and soccer players. Research on double posteromedial portal endoscopy reports a timeframe ranging from 9 to 14 weeks and states that this compares favorably with published military-population literature but less favorably with outcomes reported for dancers. Another study found that clinical features of PAIS were not associated with imaging findings in elite ballet dancers and athletes, including differing counts for the Stieda process and bone marrow edema.
Evidence Gaps Limit Certainty
The available literature does not support confident evidence-based recommendations for conservative treatment of PAIS or FHL tendinopathy in dancers. The 2018 review found only six relevant publications covering 33 ankles in 28 dancers and noted that most studies omitted dance-specific baseline details such as style and participation level. When conservative treatment fails to produce adequate results, the literature identifies surgical intervention as a possible next step, but this does not resolve the underlying shortage of dancer-specific evidence.
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.
The Mechanical Demands of Dance
A systematic review describes PAIS as posterior ankle pain during plantar flexion in dancers. It identifies hyperplantarflexion beyond the ankle's physiological joint range and repeated hindfoot trauma as the greatest risk factors for onset. This frames PAIS as a condition closely connected to the demands of specific dance movements.
Rehabilitation Begins With Load Management
The listed clinical source reports that FHL tendonitis causes pain behind the ankle and under the big toe and is most common in ballet dancers, runners, and jumping athletes. It states that treatment begins with rest, activity modification, calf stretching, and anti-inflammatory measures. These measures provide a starting framework for rehabilitation, while the source does not claim that they constitute a universally effective protocol.
A Prolonged Path to Recovery
A case study describes a 32-year-old professional ballet dancer with 14 months of insidious right posterior ankle pain that worsened during en pointe work and jumping. She had already undergone six months of conservative management, including physiotherapy and an ultrasound-guided steroid injection, without adequate relief. Examination found posteromedial ankle tenderness and a painful posterior impingement test.
Future research should focus on:
<ul><li><b>Prospective Studies:</b> Designing studies that follow dancers over time, tracking their progress with specific, dance-related outcome scores.</li><li><b>Comparative Trials:</b> Comparing different conservative and surgical treatment approaches to determine which are most effective.</li><li><b>Individualized Treatment:</b> Considering factors like dance style, level of participation, and specific anatomical variations to tailor treatment plans.</li></ul>