Physio Focus: Posterior Ankle Pain in Classical Ballet

by Rachele Quested, Physiotherapist, Royal Ballet Upper School

Last year and this year I have been privileged to have been invited to present at the BASEM Annual Congress.  The British Association of Sports and Exercise Medicine have shown an increasing interest in dance over the past few years. This is brilliant news for the Healthier Dancer Program.  The ongoing education of Dr’s in some of the finer points of dance terminology, technique and particular problems is of vital importance to dancers worldwide.

This year my lecture topics were “Posterior Ankle Pain in Classical Ballet” and a workshop on screening.

As all who work with dancers are aware, posterior ankle pain and impingement is a common complaint amongst dancers.  At the RBS I spend around ¼ of my time assessing, treating and rehabilitating it.

One of the most important aspects initially is accurate diagnosis.  This includes questioning about initial onset and injuring event, length of symptoms and pinpointing exactly where and when the pain is felt.  Specific palpation and differential muscle analysis in the Flexor Hallucis Longus (FHL), Flexor Digitorum Longus (FDL)  and Tibialis Posterior (TP) muscles is crucial, as is palpation of the joint capsule (subtalar and talocrural),  regional bursae, ligaments and the posterior talar process.

The presence of an os trigonum can play a role but it should not be an initial focus.  There has been a good paper published showing that a significant number of dancers following retirement were found to have os trigonums that were completely unsymptomatic.  To paraphrase words of one of the surgeons who wrote this paper; an os trigonum that is asymptomatic should not automatically be removed and even in the presence of PA pain conservative treatment should be attempted first.

Just because there is an os trigonum does not mean it is the automatic culprit! (Calder, J, personal communication, 2009).

Much of the PA pain I see is also not the fault of the posterior ankle complex.  Issues at the hip, knee and great toe can also combine to overload this region and produce local pain. The true aetiology of the pain must be found or it will be doomed to return.

I have taken some pointers from the shoulder impingement literature and characterise PA pain as Structural or Dynamic in origin.  Structural refers to the presence of a Steida Process, an os trigonum, issues associated with a Haglund’s Deformity.  It also includes variations in muscle anatomy.  For example the FHL can have a lower lying muscle belly which gets impinged as it tries to glide through the fibro-osseous tunnel between the medial and lateral posterior talar processes.

Dynamic Impingement gives those of us working conservatively with dancers much more to work with. Causes of Dynamic Impingement of the posterior ankle complex include FHL weakness, calf weakness, imbalance between the invertors and evertors and an inability to get the body’s line of gravity going correctly through the talocrural joint (TCJ).

The FHL arises from the lower 2/3 of the posterior surface of the fibula and the adjacent intermuscular septum and attaches to the base of the distal phalanx of the big toe (  The tendon moves between the talar processes and within the sustenaculum tali as it travels.  With the big toe fixed (en pointe/demipointe) it works as a stabiliser to align the leg over the great toe.  Conversely when jumping the FHL works as a powerful push off muscle.  Problems arising from weakness or insufficiency in the FHL include inability to ground the big toe going into demipointe and before jumping or poor endurance in the en pointe position.  The sheath around the tendon may become inflamed (tenosynovitis), the tendon may undergo a tendinopathy, the muscle may acutely tear and the muscle and/or tendon can become impinged at a number of sites along the length of it.

Calf weakness in my opinion is a major factor in dance injuries.

A magic number of 25 good quality single leg calf rises seems to be a good starting point, first introduced to me by Sue Mayes the inspirational physiotherapist at the Australian Ballet (lecture 2008). Poor use of the calves may leave the posterior ankle vulnerable.

An imbalance between the evertors and invertors may exist, particularly in those with a history of ankle sprains. Sickling while on demipointe or en pointe  will compress the medial aspect of the posterior ankle and stretch the lateral.

Finally an inability to get the body over the ankle can be caused by insufficient plantarflexion of the ankle, insufficient subtalar joint eversion or great toe extension.  More proximally it may relate to issues at the knees, hips or pelvis.

Once problems have been identified then the business end of treatment and particularly rehabilitation can begin.

Os trigonum FHL insufficiency
Steida process Calf weakness
FHL anatomy Imbalance between evertors-invertors
Haglunds Deformity Line of gravity not correctly through TCJ



Medial – towards the centre or midline of the body

Lateral – towards the outside or away from the midline of the body

Posterior – towards the back of the body

Anterior – towards the front of the body

Proximal – towards the centre of the body, or another structure

Distal – away from the centre of the body, or another structure

Inverter – muscle which turns the sole of the foot inward

Everter – muscle which turns the sole of the foot outward

Plantar – on or towards the sole of the foot

Dorsal – on or towards the top of the foot (or back of the hand)

Flexion – decreasing the inner angle of the joint (bending it)

Extension – increasing the inner angle of the joint (straightening it)

Palpation – examining by careful feeling with the hands and fingertips

Septum – a partition or dividing wall within an anatomical structure

Crural – relating to the leg

Sustenaculum – any anatomical structure that supports another structure

Originally published in Dance UK  magazine, Issue 78 – 2010