• K Michael Rowley, Hai-Jung Steffi Shih, Kristen Traina, Brooke Winder, Pamela Mikkelsen, and Kornelia Kulig.
• Division of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA, USA. Electronic address: kmichaelrowley@pt.usc.edu.
• Clin Biomech (Bristol, Avon). 2021 Mar 1; 83: 105287.

BackgroundTendinopathy of the flexor hallucis longus, commonly called "dancer's tendinitis", is a prevalent injury among female ballet dancers. Limited success of non-surgical interventions leads to many dancers undergoing tenolysis surgeries with risks and recovery times that can be detrimental to a dance career. The purpose of this study was to evaluate lower limb kinematics and muscle coordination during a modified traditional heel raise exercise where the toes hang off the edge of the support surface. We hypothesized this would decrease activation of the flexor hallucis longus and increase activation of larger plantarflexors.MethodsHealthy non-dancers (n = 11), healthy dancers (n = 10), and dancers with flexor hallucis longus tendinopathy (n = 9) performed traditional ("toes-on") and modified ("toes-off") heel raises with kinematic and electromyographic instrumentation of the lower leg.FindingsParticipants maintained ankle excursion with the toes-off modification, while metatarsophalangeal joints had reduced excursion and greater excursion variability. Most healthy dancers (9/10) decreased flexor hallucis longus activation as predicted, but dancers with flexor hallucis longus tendinopathy showed a variable response with some decreasing activation (3/9) but others increasing activation up to 4-times. There were no changes in activation of other plantarflexors. Across groups, intrinsic foot muscle activation decreased with the toes-off modification.InterpretationThe toes-off modification decreased flexor hallucis longus activation in most of the healthy dancers but was insufficient to shift muscle coordination from the flexor hallucis longus to larger plantarflexors in dancers with flexor hallucis longus tendinopathy. Future work should investigate clinical cues or modifications to this "toes-off" heel raise intervention.Copyright © 2021 Elsevier Ltd. All rights reserved.

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