Pinchy Ankles with Pointe?

If you’ve been keeping up with our blog posts you’ve already learned that the foot and ankle is the most common body part injured in dancers. Maybe you haven’t sprained your ankle before, but you’ve had annoying pain at the back part of your ankle. We’re going to dig a little deeper into some of the common diagnoses associated with pain at the back part of your ankle specifically while your foot is in what we refer to as plantarflexed in physical therapy or what you may know as a demi-pointe or pointe position. 

When you have pain or pinching symptoms at the back of your ankle along with a noticeable decrease in plantar flexion range of motion this can frequently be due to soft tissue or bony structures being compressed due to repeated plantarflexion demands at your ankle. This is what we refer to as posterior ankle impingement or when it involves the presence of an os trigonum (accessory bone) being compressed it is called os trigonum syndrome. This bony structure gets in the way of your tibia (lower leg bone) and calcaneus (heel bone) as they come closer together during ankle plantarflexion. A soft tissue structure that may be involved is your FHL (flexor hallucis longus) tendon that is responsible for flexion of your great toe, an important muscle especially for dancers. Dancers can be particularly susceptible to posterior ankle impingement due to the amount of time spent in extreme plantarflexed positions while placing force in a full weight bearing position in demi-pointe or pointe. 

When you are dancing and utilizing demi-pointe and pointe positions while dealing with pain at the back of your ankle and decreased range of motion in plantarflexion, this could also lead to subsequent other problems. For example, when your ankle isn’t able to achieve full plantarflexion on one side you may be placing increased stress on your peroneal muscles and tendons on the outside of your ankle as your foot is forced into a sickled position as a compensation when trying to achieve a fully plantarflexed position.

Another common diagnosis associated with ankle pain in pointe is FHL (flexor hallucis longus) tendinopathy, which as mentioned earlier is an important muscle of the dancer’s foot. This tendinopathy may be caused by faulty dance technique, specific anatomy variations, or overuse. Sometimes a dancer can actually have both FHL tendinopathy as well as posterior ankle impingement at the same time. We know that the foot and ankle is the most common area injured in dancers, and it is also interesting to note that of the foot and ankle injuries, posterior ankle impingement and FHL tendinopathy make up half of these foot and ankle injuries. 

So, what happens now? Conservative management of posterior ankle pain can absolutely be addressed with physical therapy with a dance medicine specialist, just like us at Graceful PT! After a thorough evaluation we will emphasize strategies to encourage more space between your tibia bone and calcaneus while plantarflexed where this compression occurs. One example is by focusing on strengthening and using the deeper lower leg muscles. Your evaluation will allow us to determine areas we need to address that are specific to you! We look to find the cause of your issue and not just treat your symptoms. 

Sometimes if conservative care is not successful, surgery may be recommended to remove the accessory bone followed by a course of physical therapy post-operatively to successfully rehabilitate and return to dance. At Graceful PT we strive to be your solution so that you can remain strong and healthy for a long dance career! Connect with us at kristin@gracefulpt.com.

Originally Posted June 27, 2023.

Albisetti W, Ometti M, Pascale V, and De Bartolomeo O. Clinical Evaluation and Treatment of Posterior Impingement in Dancers. Am. J. Phys. Med. Rehabil. May 2009. 88(5): 349-354.

Rietveld ABM, Hagemans FMT, Haitjema S, Vissers T, and Nelissen R. Results of Treatment of Posterior Ankle Impingement Syndrome and Flexor Hallucis Longus Tendinopathy in Dancers: A Systematic Review. Journal of Dance Medicine and Science. 2018. 22(1): 19-32.

Russell J A, Kruse D W, Koutedkis Y, McEwan I M, and Wynn M A. Pathoanatomy of Posterior Ankle Impingement in Ballet Dancers. Clinical Anatomy. 2010. 23: 613-621.