Working Diagnosis:
Hallux saltans secondary to flexor hallucis longus tenosynovitis

Treatment:
The patient completed ten sessions of physical therapy with iontophoresis, rested from pointe classes for six weeks, modified activity to keep pain less than 4/10, and used naproxen as needed. Following this course of conservative management, she reported subjective resolution of pain and demonstrated clinical improvement on physical exam with no foot/ankle tenderness or pain elicited on plantar flexion.

Outcome:
After six weeks of conservative treatment, she successfully returned to dancing and continued performing in college. She maintains weekly physical therapy sessions and, while she still experiences some clicking, she denies pain and is dancing at her maximal performance ability.

Author's Comments:
This case demonstrates a relatively uncommon case of hallux saltans or "trigger toe" secondary to flexor hallucis longus tenosynovitis. The condition, though rare, is increasingly diagnosed in ballet dancers due to repetitive plantar flexion in pointe work. There is no definitive treatment algorithm, and most published cases report failure of conservative therapy, proceeding to surgery. However, this patient experienced improvement of symptoms with nonoperative measures including nonsteroidal anti-inflammatory drugs and rest. This case highlights the potential for conservative management in select cases, though further research is needed to establish standardized protocols and identify predictors of non-surgical success.

Editor's Comments:
Flexor hallucis longus (FHL) tenosynovitis, also known as "dancer's ankle" has a multifactorial etiology. A patient's sport, level of activity, and a careful gait analysis provide valuable information in making the proper diagnosis. Conservative management can include strengthening of the foot core musculature, gait retraining. Use of steroid injections has also been reported. Hallux saltans, with both unilateral and bilateral involvement can also be associated with FHL tenosynovisitis. When nonoperative management is unsuccessful, tenolysis can be considered.

References:
Eggers-Stroeder G, Bruns J. Der Trigger-Hallux--eine seltene Ursache des Innenknöchelschmerzes [Trigger hallux--a rare cause of pain at the inner malleolus]. Z Orthop Ihre Grenzgeb. 1991;129(1):48-50. doi:10.1055/s-2008-1040158 <br>Lereim P. Trigger toe in classical-ballet dancers. Arch Orthop Trauma Surg (1978). 1985;104(5):325-326. doi:10.1007/BF00435951 <br>Martinez-Salazar EL, Vicentini JRT, Johnson AH, Torriani M. Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings. Skeletal Radiol. 2018;47(5):747-750. doi:10.1007/s00256-017-2853-9 <br>McCarroll JR, Ritter MA, Becker TE. Triggering of the great toe. A case report. Clin Orthop Relat Res. 1983;(175):184-185. <br>Newman NM, Fowles JV. A case of "trigger toe". Can J Surg. 1984;27(4):378-379. <br> <br>Gasti AV, James R, Neumayer F. Bilateral hallux Saltans, a Rare Finding: Diagnosis and Arthroscopic Treatment in a Young Ballet Dancer: Report of a Case. J Orthop Case Rep. 2025;15(4):161-166. doi:10.13107/jocr.2025.v15.i04.5484 <br> <br>Rohan, Sundarapandian R, Pillai A. A Rare Case of Hallux Saltans Treated using Ultrasound-guided Intralesional Steroid Injection: A Case Report. J Orthop Case Rep. 2024;14(6):52-55. doi:10.13107/jocr.2024.v14.i06.4500

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