Posterior Ankle Pain in Dancers: Os Trigonum Syndrome and FHL Tendinopathy

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Posterior ankle pain in dancers — particularly classical ballet dancers who repeatedly go en pointe or demi-pointe — has two common causes: os trigonum syndrome (impingement of the os trigonum between the tibia and calcaneus in forced plantarflexion) and flexor hallucis longus (FHL) tendinopathy or triggering. Both conditions produce posterior ankle pain with plantarflexion and are specifically associated with activities requiring maximal ankle plantarflexion. Distinguishing them is important because their surgical treatments are different, though they frequently coexist.

Os Trigonum Syndrome

The os trigonum is a secondary ossification center of the posterior talar process — present in 7–25% of the population — that fails to fuse with the talus and remains as a separate bone connected by a synchondrosis. In forced plantarflexion (ballet pointe position, football kicking, soccer striking), the os trigonum is compressed between the posterior tibia and the superior calcaneus — producing posterior ankle pain. Clinical features: posterior ankle pain reproduced with passive forced plantarflexion (the posterior impingement test); point tenderness posterior to the peroneal tendons in the retromalleolar-calcaneal space; the FHL tendon runs adjacent to the os trigonum and is often simultaneously inflamed. Imaging: lateral X-ray identifies the os trigonum; MRI shows edema at the synchondrosis and surrounding soft tissue inflammation. Conservative management: activity modification (reduce pointe work); corticosteroid injection at the os trigonum synchondrosis under ultrasound guidance; boot immobilization for acute flare. Surgical: posterior arthroscopic os trigonum excision — 6–8 weeks recovery; excellent results in dancers with early return to dance.

FHL Tendinopathy and Triggering

The FHL tendon passes through a fibro-osseous tunnel at the posterior ankle adjacent to the os trigonum — stenosis of this tunnel or FHL tendon thickening produces triggering (‘dancer’s tendinitis’): a palpable and audible clicking or snapping with active great toe flexion-extension, sometimes with the great toe intermittently locking in flexion. Treatment: FHL tendon sheath corticosteroid injection; FHL tendon sheath release (tenosynovectomy) when conservative management fails — usually performed concurrently with os trigonum excision when both are present. Dr. Biernacki at Balance Foot & Ankle evaluates posterior ankle pain with dynamic ultrasound and treats os trigonum syndrome and FHL tendinopathy in dancers and athletes. Call (810) 206-1402 at our Bloomfield Hills or Howell office.

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In-Office Treatment at Balance Foot & Ankle

If home care isn’t resolving your ankle pain, a visit with a board-certified podiatrist is the fastest path to accurate diagnosis and a personalized plan. At Balance Foot & Ankle Specialists, Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin offer same-day and next-day appointments at both our Howell and Bloomfield Hills offices. We perform on-site diagnostic ultrasound, digital X-ray, conservative care, advanced regenerative treatments, and minimally invasive surgery when indicated.

Call (810) 206-1402 or request an appointment online. Most insurance plans accepted, including Medicare, Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare.

Frequently Asked Questions

How do I know if I sprained or broke my ankle?

Both cause pain, swelling, and difficulty walking. Key differences: fractures often cause more immediate severe pain, tenderness directly over bone (not just ligament), and inability to bear any weight. X-rays and the Ottawa Ankle Rules help determine if imaging is needed.

How long does an ankle sprain take to heal?

Grade I (mild): 1–2 weeks. Grade II (moderate): 3–6 weeks. Grade III (complete tear): 2–3 months. Chronic instability from improperly treated sprains can persist and may require surgery.

What is the best treatment for a sprained ankle?

RICE protocol (Rest, Ice, Compression, Elevation) for the first 48–72 hours, followed by protected weight-bearing as tolerated. Physical therapy rehabilitation is critical for high-grade sprains to restore strength and proprioception and prevent chronic instability.

Need Treatment at Balance Foot & Ankle?

Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients at our Howell and Bloomfield Hills offices.

Book Online or call (810) 206-1402

Most Common Mistake We See

The most common mistake we see is: Waiting too long before seeking care. Fix: any foot pain lasting more than 4 weeks, or any sudden severe symptom, deserves a professional evaluation rather than more rest.

Warning Signs That Need Same-Day Care

Frequently Asked Questions

When should I see a doctor?

See a podiatrist if pain persists past 2 weeks, prevents normal activity, or is accompanied by red-flag symptoms (warmth, swelling, numbness, inability to bear weight).

Can I treat this at home?

Mild cases respond to RICE protocol (rest, ice, compression, elevation), supportive shoes, and OTC anti-inflammatories. Persistent symptoms need professional evaluation.

How long does it take to heal?

Most soft tissue injuries resolve in 2-6 weeks with appropriate care. Bone injuries take 6-12 weeks. Chronic conditions need longer-term management.

What is Foot pain?

Foot pain is a common foot/ankle condition that affects mobility and quality of life. Understanding the underlying cause is the first step in successful treatment. Our podiatrists at Balance Foot & Ankle perform a hands-on biomechanical exam, review your activity history, and use diagnostic imaging when appropriate to identify the root cause—not just treat the symptom. Many patients have been told to “rest and ice” without a deeper diagnostic workup; our approach is different.

Symptoms and warning signs

Common signs of foot pain include pain that worsens with activity, morning stiffness, swelling, tenderness when palpated, and difficulty bearing weight. If you experience sudden severe pain, inability to walk, visible deformity, numbness or color change, contact our office the same day or visit urgent care—these can signal a more serious injury such as a fracture, tendon rupture, or vascular compromise. Diabetics with any foot wound should seek same-day care.

Conservative treatment options

Most cases of foot pain respond to non-surgical care: structured rest, supportive footwear changes, custom orthotics, targeted stretching and strengthening protocols, anti-inflammatory medications when medically appropriate, and in-office procedures such as ultrasound-guided injections. We also offer advanced therapies including MLS laser therapy, EPAT/shockwave, regenerative injections, and image-guided procedures. Treatment is sequenced from least invasive to most invasive, and we explain the rationale at every step.

When is surgery considered?

Surgery is reserved for cases that fail 3-6 months of well-structured conservative care, when there is structural pathology (severe deformity, complete tear, advanced arthritis), or when imaging shows damage that will not heal without intervention. Our surgeons have performed 3,000+ foot and ankle procedures and prioritize minimally-invasive techniques whenever appropriate. We discuss recovery timelines, return-to-activity milestones, and realistic outcome expectations before any procedure is scheduled.

Recovery timeline and prevention

Recovery from foot pain varies based on severity and chosen treatment path. Conservative cases often improve within 4-8 weeks with consistent adherence to the protocol. Post-procedural recovery may range from a few days (in-office procedures) to several months (reconstructive surgery). Long-term prevention involves footwear assessment, activity modification, structured strengthening, and regular check-ins with your podiatrist if you have a history of recurrence. We provide written home-exercise plans and digital follow-up support.