FHL - the big toe
What is the last part of the foot that leaves the ground when you rise up onto pointe? what is that last part of the foot that leaves the ground when you walk and run? The big toe. Oh mighty big toe, how much we expect of you. We take you for granted until you don’t work anymore. From bunions to bruised toe nails from inappropriately fitted pointe shoes, sesamoiditis, fractures, FHL tendonitis, so much can go wrong with the mighty big toe. Did you know that many of the toes can be fractured and we just buddy tape them? (unless they are unstable fractures). While with the big toe we can’t get away with such treatment, you break your big toe, it needs immobilising. Why? because it is crucial for walking normally.
Today I thought I’d discuss Flexor Hallicus Longus (FHL) issues as it is a more common issue in the dance population. The FHL is the powerhouse of movement when it comes to the big toe and dancers, it literally pointes your toe! But what happens when we rely on it too much?
Dysfunction of the FHL is particularly typical in a dancing population occurring due to repetitive loading or forced pointing. So literally the more you pointe the worse it gets! It starts off as a tendonitis and can fast track to a tendinopathy if it is mismanaged. Which as a result contributes to posterior ankle impingement which is a chronic condition. Tendonitis of the FHL will happen if the friction continues to occur of the tendon through the fibre-osseous tunnel with repeated activities such as pointe work. The more we load despite irritation, the worse the tendon gets and it begins to thicken and catch in the tunnel which can create bunching of the tendon and a claw like look to the big toe. Yuck, try getting your foot into a pointe shoe then and forget open toed shoes.
Signs and Symptoms
Pain on rise to demi pointe, back of the ankle but also can occur under the foot
pain with pointing the toe and foot
a clunking sensation on the inside of the ankle (chronic issue)
pain on jumping, sautes, one legged jumps
weak calf muscles
clawing toes with tendu, pointe, with stance
poor ankle stability with fishing or sickling on assessment
weak medial arch control
losses in talocrural joint (ankle joint) ranges
pain on overpressure calcaneus on plantar flexion (pointing)
What’s to be done? short answer…catch it early, the longer it goes on the harder it is to resolve. Early diagnosis of FHL overload is beneficial for long term prognosis. We focus on settling the tendon and beginning low grade loading regimes with some specific balance work and stretching as tolerated. In some unsuccessful cases surgery is warranted. And while successful, the rehabilitation phase is long and you will be restricted with your loading by the surgeon for quite some time.
So love your big toe, it does a lot for you