Chris G. Koutures, MD, FAAP Pediatric and sports medicine specialist

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USA Volleyball Mens/Womens National Teams
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Pediatric Sports Medicine: Essentials for Office Evaluation

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Filtering by Tag: Limitations in big toe motion in dancers

Seven Practical Observations on Dealing with Shin Pain in Athletes

After seeing plenty of shin pain in ballet Nutcracker performers , Olympic Volleyball players and various other athletic activities , here are 7 practical clinical observations to help assess and treat this common problem.

1)      Look above the shin

Landing  from a jump with inadequate hip or buttock strength can lead to an inward collapse of the knee, placing abnormal rotational forces on the shin.  Similar lack of upper leg control can lead to collapse of the foot arch in running, again causing increased stress on the shin. Any complete evaluation of shin pain should include some form of hip/buttock strength- my favorites include the single-leg squat, step-ups,or plie in 2nd position for dancers. Ideal alignment has kneecap directly under the hip and over the 2nd toe.

Plie in second position: note kneecap directly under hip and over 2nd toe

Plie in second position: note kneecap directly under hip and over 2nd toe

2)      Look immediately below the shin

Decreased ankle dorsiflexion (ability to move shin towards the foot or foot toward the shin)is yet another contributor to increased stress of the shin bones. Common causes include tight calf muscles or restricted movements between the tibia (shin bone) and the talus (first bone of the foot).  Side-to-side dorsiflexion motion comparisons can help identify abnormalities.

3)      Try to stand on toes or walk on the outside of the foot

If the calcaenous (heel bone) doesn’t move inward when standing on the toes, or if there is an inability to walk comfortably on the outside border of the foot, start thinking about restricted midfoot subtalar joint motion. Much like limited dorsiflexion, subtalar dysfunction transmits excessive forces to the shin region.  Tarsal coalition is a fairly common and under-recognized form of subtalar restriction.

4)      Never under appreciate the importance of the big toe

Amazing how restrictions within the small 1st metatarsophalangeal joint (aka big toe joint) can lead to big problems in the shin. Limited ability to raise the big toe off the ground toward the shin leads to either increased pressure on the outside of the foot or higher forces on the front of the shin during foot impact with the ground.  Stretching of the flexor hallicus longus muscle that controls big toe motion can be life and career-saving.

5)      Stressful causes of cramping calves

While most forms of generalized tightness or cramping in the calves are usually due to muscle fatigue and relative overuse, be more suspicious of cramps that can be pointed out by a finger tip and are located right next to the upper part of the tibia bone. Have found 2 recent cases of tibial stress reactions that presented with the primary concern of localized calf cramps.

6)      How are the iron stores?

Some cases of long-standing or difficult to treat shin pain may be complicated by low ferritin (measure of iron stores in the body).  More likely in females with heavier menstrual losses or those athletes and performers with restricted dietary iron intake.  I will routinely order laboratory testing in my evaluation of challenging shin pain.

7)      What are you wearing on your feet?



Practicing in Southern California, I often see patients who will select the best in athletic footwear, but then come into my office and routinely report wearing ill-fitting or poorly supportive shoes or sandals for non-athletic activities.  I’ve learned that if you can twist a shoe or sandal like a rolled newspaper, then there isn’t much mid-foot support. Use of relatively inexpensive over-the-counter arch supports in daily use shoes can allow one to be both fashionable and functional, while leaving sandals for the pool or beach.



Dr. Koutures Speaks at ABT-Gillespie School at Segerstrom Center on Young Dancer Health

How Little Limitations in Big Toe Motion Cause Big Problems in Dancers

In my evaluations of dancers with foot, ankle, knee or even hip pain, I tend to find that the root cause of these issues often starts with abnormal motion of the big toe joint (aka first metatarsalphalangeal joint or 1st MTP joint).

While some may question how such a small joint can cause such a great list of problems, a quick review of common dance positions provides reasons why optimal big toe function is so essential for healthy dance.

In demi-pointe, a dancer ideally should achieve full big toe dorsiflexion, which is where the big toe is able to be lifted up in the air and positioned closer to the rest of the foot.



Limitations in big toe dorsiflexion, known as hallux rigidus, lead to painful compensations or changes in function at several joints:

  • Sickling or putting more pressure on the outside of the foot which not only does not look appealing, but increases the risk of ankle sprains or even damage to the bones on the outside of the foot



  • Forcing the knees into a more forward position (can't see toes when in squatting position) which places abnormal stresses on the front of the knee joint
  • Increasing the need to flex or bend the hips, which also places an unusual demand on these joints

One cause of 1st MTP/big toe limited range of motion is osteophytes, which are deposits of extra bone growth in the joint.  Unfortunately, surgical removal is necessary and many a dancer's career has been shortened due to such destructive arthritis.

A more common cause of 1st MTP motion, especially in the school-age dancer, is dysfunction of the Flexor Hallicus Longus (FHL) tendon that follows a course along the inside of the foot and ends at the big toe. 

Restriction of the FHL routinely occurs in three spots and can significantly limit 1st MTP/big toe dorsiflexion:

  • Tarsal Tunnel at inside of ankle (STAR)
  • Intersection of FHL with neighboring Flexor Digitorum Longus tendon (TRIANGLE)
  • Attachment of FHL to the first bone (proximal phalange) of the big toe (SQUARE)

 A nice review of FHL dysfunction in dancers can be found here.

I have found that aggressive stretching of the FHL combined with intense friction massage at those three points of narrowing is needed to help dancers overcome this issue. While best results tend to come after working with a trained medical professional, self or home-based massage items include tennis balls, golf balls, and ice blocks (paper ice cups are a favorite).

How aggressive and intense does this treatment need to be?

Let's just say that the stretching and massage can be uncomfortable, bordering on painful, and it is not uncommon to have bruising of the foot if proper aggressive intensity has been found. Warning a dancer ahead of time about the potential pain and bruising helps prepare them and increases changes for favorable outcomes.

How have other dancers or medical professionals encountered issues with the Big Toe and what techniques have been learned to deal with the problems?