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

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Comprehensive blend of general pediatric and sport medicine care with an individualized approach that enhances the health and knowledge of patients and their families



Proud physician:
USA Volleyball Mens/Womens National Teams
CS Fullerton Intercollegiate Athletics
Chapman University Dance Department
Orange Lutheran High School

Co-Author of Acclaimed Textbook

Pediatric Sports Medicine: Essentials for Office Evaluation

Orange County Physician Of Excellence, 2015 and 2016


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?