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Sockalingam N, Reymond N, Rybnikov A, Dubois-Ferriere V, Assal M. Do Patients With Functional Hallux Limitus Have a Low-Lying or Bulky FHL Muscle Belly? FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231153140. [PMID: 36860802 PMCID: PMC9969446 DOI: 10.1177/24730114231153140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
Background Functional hallux limitus (FHLim) refers to a limitation of hallux dorsiflexion when the first metatarsal head is under load, whereas physiologic dorsiflexion is measured in the unloaded condition. Limited excursion of the flexor hallucis longus (FHL) in the retrotalar pulley has been identified as a possible cause of FHLim. A low-lying or bulky FHL muscle belly could be the cause of this limitation. However, to date, there are no published data regarding the association between clinical and anatomical findings. The purpose of this anatomical study is to correlate the presence of FHLim and objective morphologic findings through magnetic resonance imaging (MRI). Methods Twenty-six patients (27 feet) were included in this observational study. They were divided into 2 groups, based on positive and negative Stretch Tests. In both groups, we measured on MRI the distance from the most inferior part of the FHL muscle belly and the retrotalar pulley as well as the cross-sectional area of the muscle belly 20, 30, and 40 mm proximal to the retrotalar pulley. Results Eighteen patients had a positive Stretch Test and 9 patients had a negative Stretch Test. The mean distance between the most inferior part of the FHL muscle belly and the retrotalar pulley was 6.0 ± 6.4 mm for the positive group and 11.8 ± 9.4 mm for the negative group (P = .039). The mean cross section of the muscle measured at 20, 30, and 40 mm from the pulley were 190 ± 90, 300 ± 112, and 395 ± 123 mm2 for the positive group and 98 ± 44, 206 ± 72, and 294 ± 61mm2 for the negative group (P values .005, .019, and .017). Conclusion Based on these findings, we can conclude that patients with FHLim do have a low-lying FHL muscle belly causing limited excursion in the retrotalar pulley. However, the mean volume of the muscle belly was comparable in both groups, and therefore bulkiness was not found to be a contributing factor. Level of Evidence Level III, observational study.
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Affiliation(s)
- Navindravadhanam Sockalingam
- Centre ASSAL for Foot Care and Surgery,
Hirslanden Clinique La Colline, Geneva, Switzerland,Navindravadhanam Sockalingam, MS Ortho,
Centre ASSAL for Foot Care and Surgery, Hirslanden Clinique La Colline, Av de
Beau-Séjour 6, Genève, 1206, Switzerland.
| | - Nils Reymond
- Centre ASSAL for Foot Care and Surgery,
Hirslanden Clinique La Colline, Geneva, Switzerland
| | - Alexey Rybnikov
- Centre ASSAL for Foot Care and Surgery,
Hirslanden Clinique La Colline, Geneva, Switzerland
| | - Victor Dubois-Ferriere
- Centre ASSAL for Foot Care and Surgery,
Hirslanden Clinique La Colline, Geneva, Switzerland
| | - Mathieu Assal
- Centre ASSAL for Foot Care and Surgery,
Hirslanden Clinique La Colline, Geneva, Switzerland
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Michelson JD, Bernknopf JW, Charlson MD, Merena SJ, Stone LM. What Is the Efficacy of a Nonoperative Program Including a Specific Stretching Protocol for Flexor Hallucis Longus Tendonitis? Clin Orthop Relat Res 2021; 479:2667-2676. [PMID: 34170867 PMCID: PMC8726539 DOI: 10.1097/corr.0000000000001867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/28/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Diagnosis and treatment of tendonitis/entrapment of the flexor hallucis longus (FHL) has been sporadically described in the evidence, primarily in the context of dancers and other athletes. Although various nonspecific nonoperative treatments have been described, it is not clear how often they achieve a satisfactory amount of symptom improvement. QUESTIONS/PURPOSES The present study was designed to address the following questions regarding the nonoperative treatment of FHL tendonitis: (1) In a population of patients where the default management option for FHL tendonitis is a comprehensive nonsurgical approach, what proportion of patients thus treated opted not to have surgery? (2) What factors were associated with a patient's decision to undergo surgery after a period of nonsurgical management? METHODS The 656 patients included were all those diagnosed with FHL tendonitis who were initially treated nonoperatively in the foot and ankle division between January 2009 and December 2018. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and final outcome were obtained from the electronic medical record. The primary outcome was the decision to have surgery due to unsatisfactory symptom improvement. We compared patients who opted for surgery with those who did not after nonoperative treatment with univariable and multivariable statistics using demographics, comorbidities, and clinical findings as potential risk factors, with p < 0.05. RESULTS Forty-four percent (180 of 409) of patients decided to forgo surgery after the institution of a specific FHL stretching program. Surgery was more likely in patients with clinical hallux rigidus (OR 2.4 [95% CI 1.16 to 4.97]; p = 0.02) or posteromedial ankle pain (OR 1.78 [95% CI 1.12 to 2.83]; p = 0.01) and less likely in those who completed an FHL stretching program (OR 0.15 [95% CI 0.08 to 0.27]; p < 0.001). CONCLUSION FHL tendonitis is more common than the previous evidence suggests and frequently occurs in nonathletes. Once it was diagnosed by detection of tenderness anywhere along the tendon, most frequently at the fibroosseous tunnel, nonoperative treatment focused on specific FHL stretching and immobilization in more severe cases reduced the symptoms to the extent that 44% of patients decided that surgery was unnecessary. The key to its diagnosis is awareness that this injury is possible because most patients treated in this study had been previously seen by orthopaedic providers who had not appreciated the presence of the condition, leading to a delay in diagnosis and treatment of more than a year in many patients. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- James D. Michelson
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Jacob W. Bernknopf
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Mark D. Charlson
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Stephen J. Merena
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
| | - Lara M. Stone
- Department of Orthopaedics and Rehabilitation, Larner College of Medicine, University of Vermont, Burlington, VT, USA
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MRI findings of tibialis anterior friction syndrome: a mimic of tibial stress injury. Skeletal Radiol 2021; 50:2007-2011. [PMID: 33768274 DOI: 10.1007/s00256-021-03756-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/07/2021] [Accepted: 03/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe a distinct constellation of MRI demonstrated soft tissue abnormalities centred around the tibialis anterior tendon in a subset of patients presenting as suspected tibial stress injury. MATERIALS AND METHODS A retrospective review was performed of the clinical and MRI imaging findings from 5 selected patients referred for MRI with suspected tibial stress injury. MRI studies at presentation of each case were systematically reviewed for peritendinous fluid, tibialis anterior tendon change, tibialis anterior muscle and myotendinous junction oedema, periosteal oedema over the tibia and tibial marrow oedema. RESULTS All 5 cases were athletes (3 soccer players, 2 runners) of between 20 and 40 years of age. On MRI, all 5 cases demonstrated peritendinous fluid around an intact tibialis anterior tendon. This fluid was maximal at the junction of mid and distal thirds of the lower leg, and extended down to the superior extensor retinaculum, with a mean cranio-caudal length of 13 cm (range 8-17 cm). Associated oedema was present in the surrounding subcutaneous tissue, tibial periosteum and distal tibialis anterior musculotendinous junction. CONCLUSION Peritendinous fluid around an intact tibialis anterior tendon over the mid-to-distal third tibia, with surrounding subcutaneous, periosteal and tibialis anterior myotendinous junction oedema is demonstrable on MRI in a subset of patients presenting as suspected tibial stress injury. A friction syndrome of tibialis anterior between the superior extensor retinaculum and the anterior tibia is proposed as the aetiology of this entity.
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Michelson J, O'Keefe J, Bougioukas L. Increased flexor hallucis longus tension decreases ankle dorsiflexion. Foot Ankle Surg 2021; 27:550-554. [PMID: 32739176 DOI: 10.1016/j.fas.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/09/2020] [Accepted: 07/13/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Restricted excursion of the flexor hallucis longus (FHL) is associated with several clinical problems. An FHL excursion measurement device (EMD) was used to objectively assess differences between patients with clinically normal or tight FHL tendons. METHODS 188 patients (356 feet) were enrolled. The EMD measured maximum ankle dorsiflexion with the great toe in 15°, 30°, and 45° of dorsiflexion. All had clinical assessment of FHL tightness by their provider independently of the EMD measurement. RESULTS Increased hallux DF always caused decreased ankle DF. Patients with clinically tight FHLs demonstrated decreased ankle DF compared to normal subjects at all hallux positions (p<0.01). The EMD measurement was not sensitive enough for detection of FHL tightness in individuals. A clinically tight FHL was seen in almost 50% of feet. CONCLUSIONS Tension in the FHL can limit ankle DF. Clinical tightness of the FHL is likely more common than currently recognized.
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Affiliation(s)
- James Michelson
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA.
| | - John O'Keefe
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA
| | - Lauren Bougioukas
- University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA
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Newman DP, Holkup KC, Jacobs AN, Gallo AC. Recalcitrant Flexor Hallucis Longus Dysfunction: A Case Study Demonstrating the Successful Application of an Adaptable Rehabilitation Program With a Two-Year Follow-Up. Cureus 2021; 13:e14326. [PMID: 34079644 PMCID: PMC8159326 DOI: 10.7759/cureus.14326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Flexor hallucis longus (FHL) dysfunction is a condition experienced primarily by athletes, including ballet dancers and runners. Accurate diagnosis and definitive treatment at the initial evaluation can often be difficult given the number of foot and ankle pathologies that share similar signs and symptoms. The evaluation process tends to be a diagnosis of inclusion rather than a specific pathology with an accepted rehabilitation plan. For example, patients with medial arch pain may undergo an extended rehabilitation period with an evolving differential diagnosis requiring several treatment modifications. A more appropriate rehabilitation paradigm should adapt to the potential changes in patient symptoms and presentation, addressing functional impairments as they arise. This case study describes the successful management of a patient with chronic FHL dysfunction, leveraging a flexible, multimodal treatment approach to address the evolving functional impairments rather than focusing on a single, discrete diagnosis. At a two-year follow-up, the patient remains pain-free.
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Affiliation(s)
- David P Newman
- Pain Management-Physiotherapy, Tripler Army Medical Center, Honolulu, USA
| | | | - Aimee N Jacobs
- Physical Therapy, Tripler Army Medical Center, Honolulu, USA
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Effects of a "toes-off" modified heel raise on muscle coordination in non-dancers, dancers, and dancers with flexor hallucis longus tendinopathy. Clin Biomech (Bristol, Avon) 2021; 83:105287. [PMID: 33601167 DOI: 10.1016/j.clinbiomech.2021.105287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 01/19/2021] [Accepted: 01/26/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tendinopathy 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. METHODS Healthy 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. FINDINGS Participants 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. INTERPRETATION The 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.
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Sharpe BD, Steginsky BD, Suhling M, Vora A. Posterior Ankle Impingement and Flexor Hallucis Longus Pathology. Clin Sports Med 2020; 39:911-930. [PMID: 32892975 DOI: 10.1016/j.csm.2020.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Posterior ankle pain is a common complaint, and the potential causative pathologic processes are diverse. The constellation of these numerous etiologies has been collectively referred to as posterior ankle impingement syndrome. The pain associated with posterior ankle impingement is caused by bony or soft tissue impingement of the posterior ankle while in terminal plantar flexion. This condition is most frequently encountered in athletes who participate in sports that involve forceful, or repetitive, ankle plantar flexion. This article discusses the associated pathology, diagnosis, conservative treatment, and surgical techniques associated with flexor hallucis longus and posterior ankle impingement syndrome.
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Affiliation(s)
- B Dale Sharpe
- Residency Program, OhioHealth Orthopedic Surgery, 5100 West Broad Street, Columbus, OH 43228, USA
| | - Brian D Steginsky
- OhioHealth Orthopedic Surgeons, 303 East Town Street, Columbus, OH 43215, USA.
| | - Mallory Suhling
- Illinois Bone and Joint Institute, LLC, 720 Florsheim Drive, Libertyville, IL 60048, USA
| | - Anand Vora
- Illinois Bone and Joint Institute, LLC, 720 Florsheim Drive, Libertyville, IL 60048, USA
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Sayel FA, Pitakveerakul A, Alshalawi S, Wiewiorski M, Valderrabano V. Neglected Iatrogenic Flexor Hallucis Longus Tendon Rupture After Haglund's Endoscopic Surgery: A Case Report. J Foot Ankle Surg 2020; 59:169-172. [PMID: 31753576 DOI: 10.1053/j.jfas.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 07/08/2019] [Accepted: 07/14/2019] [Indexed: 02/03/2023]
Abstract
Rupture of the flexor hallucis longus (FHL) tendon is a rare condition that can occur with direct or indirect trauma; most of the injuries are complete ruptures resulting from laceration. Endoscopic calcaneoplasty is used for treatment of symptomatic Haglund's deformity, and complications of this procedure are rare. Iatrogenic FHL tendon rupture occurring after endoscopic calcaneoplasty has not been reported previously. This case report presents a rare complication after endoscopic calcaneoplasty and the proper method of treatment.
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Affiliation(s)
- Faisal Al Sayel
- Orthopaedic Fellow, Swiss Ortho Center, Schmerzklinik Basel, Swiss Medical Network, Basel, Switzerland
| | - Akaradech Pitakveerakul
- Orthopaedic Fellow, Department of Orthopaedic Surgery, Sirindhorn Hospital, Bangkok, Thailand
| | - Saud Alshalawi
- Orthopaedic Fellow, Orthopaedic Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Martin Wiewiorski
- Head, Foot & Ankle Unit, Orthopaedic and Trauma Department, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Victor Valderrabano
- Professor, Chairman, Orthopaedic Department, Swiss Ortho Center, Schmerzklinik Basel, Swiss Medical Network, Basel, Switzerland.
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Qu W, Liu T, Chen W, Sun Z, Dong S, Chen M. Effect of extensive tenosynovectomy on diffuse flexor hallucis longus tenosynovitis combined with effusion. J Orthop Surg (Hong Kong) 2020; 27:2309499019863355. [PMID: 31366279 DOI: 10.1177/2309499019863355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of this study was to examine the clinical and magnetic resonance imaging (MRI) outcomes of extensive tenosynovectomy on patients with diffuse flexor hallucis longus tenosynovitis combined with effusion (DFHLT-E). METHODS Consecutive patients undergoing extensive tenosynovectomy for DFHLT-E in the same foot and ankle center from January 2013 to December 2016 were selected; a total of 14 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, MRI, American Orthopaedic Foot and Ankle Society (AOFAS) clinical midfoot scale, and visual analog scale (VAS) pain scores. RESULTS The 14 patients were followed up for an average of 15.0 ± 2.3 months (12-18 months). There were no recurrences in all clinical examinations at the final follow-up. The AOFAS score was improved from 61.57 ± 10.70 before surgery to 90.28 ± 9.41 at the final follow-up. The difference was statistically significant (p = 0.001). The VAS score was improved from 4.00 ± 0.82 before surgery to 0.43 ± 0.53 at the final follow-up (p < 0.001). MRI examination revealed two patients with small residual and limited effusion with no clinical symptoms. Superficial pin infection was observed in one patient, and two patients had transient neurostimulation. CONCLUSIONS Extensive tenosynovectomy is an effective alternative for the treatment of DFHLT-E with less complications or recurrence.
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Affiliation(s)
- Wenqing Qu
- 1 Department of Foot and Ankle Surgery, Yantaishan Hospital, Yantai, China
| | - Tong Liu
- 1 Department of Foot and Ankle Surgery, Yantaishan Hospital, Yantai, China
| | - Wentao Chen
- 2 Department of Orthopedics, Friendship Hospital, Beijing, China
| | - Zhenzhong Sun
- 3 Department of Radiology, Yantaishan Hospital, Yantai, China
| | - Shengjie Dong
- 4 Department of Joint Surgery, Yantaishan Hospital, Yantai, China
| | - Mingxia Chen
- 5 Department of Pathology, Yantaishan Hospital, Yantai, China
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De-la-Cruz-Torres B, Barrera-García-Martín I, De la Cueva-Reguera M, Bravo-Aguilar M, Blanco-Morales M, Navarro-Flores E, Romero-Morales C, Abuín-Porras V. Does Function Determine the Structure? Changes in Flexor Hallucis Longus Muscle and the Associated Performance Related to Dance Modality: A Cross-Sectional Study. ACTA ACUST UNITED AC 2020; 56:medicina56040186. [PMID: 32316305 PMCID: PMC7230629 DOI: 10.3390/medicina56040186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/14/2020] [Accepted: 04/14/2020] [Indexed: 12/16/2022]
Abstract
Background and Objectives: Flexor hallucis longus pathology is one of the most common conditions of the ankle and foot in dancers, due to the high demand of dance movements performed in an extreme plantar flexion and dorsiflexion range of motion. The objectives of this study were to determine the bilateral differences between the thickness and cross-sectional area of the flexor hallucis longus muscle in dancers, to establish possible differences between dance modalities, and to analyze whether there is a correlation between ultrasonographic parameters or performance variables and the dance modality. Material and Methods: A sample of 50 (29 classical and 21 contemporary) full-time pre-professional female dancers were included in the study. The thickness and cross-sectional area of the flexor hallucis longus muscle were evaluated for both limbs using ultrasound imaging. The range of movement of the first metatarsophalangeal joint was measured using functional extension with maximal ankle plantarflexion, balance was measured in a unilateral stance with the heel raised, endurance was evaluated through a modified heel rise fatigue test, and a counter movement jump to assess the vertical jump performance was measured bilaterally. Results: There were no significant differences recorded between the dominant and non-dominant limbs for each variable, within both groups. Contemporary dancers showed a greater thickness and cross-sectional area of the flexor hallucis longus muscle than classical dancers. However, classical dancers showed an increase of balance, endurance, range of movement of the first metatarsophalangeal joint, and counter movement jump with respect to contemporary dancers. Conclusion: Bilateral symmetry was identified in all variables for both groups. The size and performance of the flexor hallucis longus muscle may be influenced by the specific nature of dance modality.
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Affiliation(s)
- Blanca De-la-Cruz-Torres
- Department of Physiotherapy, University of Seville, Avicena Street, 41009 Sevilla, Spain; (B.D.-l.-C.-T.); (I.B.-G.-M.)
| | - Irene Barrera-García-Martín
- Department of Physiotherapy, University of Seville, Avicena Street, 41009 Sevilla, Spain; (B.D.-l.-C.-T.); (I.B.-G.-M.)
| | - Mónica De la Cueva-Reguera
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain; (M.D.l.C.-R.); (M.B.-A.); (M.B.-M.); (V.A.-P.)
| | - María Bravo-Aguilar
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain; (M.D.l.C.-R.); (M.B.-A.); (M.B.-M.); (V.A.-P.)
| | - María Blanco-Morales
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain; (M.D.l.C.-R.); (M.B.-A.); (M.B.-M.); (V.A.-P.)
| | - Emmanuel Navarro-Flores
- Frailty Research Organized Group (FROG), Department of Nursing, Faculty of Nursing and Podiatry, University of Valencia, 46010 Valencia, Spain;
| | - Carlos Romero-Morales
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain; (M.D.l.C.-R.); (M.B.-A.); (M.B.-M.); (V.A.-P.)
- Correspondence:
| | - Vanesa Abuín-Porras
- Faculty of Sport Sciences, Universidad Europea de Madrid, Villaviciosa de Odón, 28670 Madrid, Spain; (M.D.l.C.-R.); (M.B.-A.); (M.B.-M.); (V.A.-P.)
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Posterior Arthroscopic Treatment of a Massive Effusion in the Flexor Hallucis Longus Tendon Sheath Associated with Stenosing Tenosynovitis and Os Trigonum. Case Rep Orthop 2020; 2020:6236302. [PMID: 32280550 PMCID: PMC7140132 DOI: 10.1155/2020/6236302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 03/14/2020] [Indexed: 11/17/2022] Open
Abstract
We report a rare case of massive accumulation of fluid in the flexor hallucis longus tendon sheath with stenosing tenosynovitis and os trigonum. A 34-year-old woman presented to our hospital with pain and swelling in the posteromedial aspect of the left ankle joint after an ankle sprain approximately 8 months earlier. There was tenderness at the posteromedial aspect of the ankle, and the pain worsened on dorsiflexion of the left great toe. Magnetic resonance imaging revealed massive accumulation of fluid around the flexor hallucis longus tendon. We removed the os trigonum, performed tenosynovectomy around the flexor hallucis longus, and released the flexor hallucis longus tendon via posterior arthroscopy using standard posterolateral and posteromedial portals. At 1 week postoperatively, the patient was asymptomatic and able to resume her daily activities. There has been no recurrence of the massive accumulation of fluid around the flexor hallucis longus tendon as of 1 year after the surgery. To our knowledge, this is a rare case report of extreme massive effusion in the flexor hallucis longus tendon sheath with stenosing tenosynovitis and os trigonum treated successfully by removal of the os trigonum, tenosynovectomy around the flexor hallucis longus, and release of the flexor hallucis longus tendon via posterior ankle arthroscopy.
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The accuracy of an injection technique for Flexor hallucis longus tendon sheath: A cadaveric study. Foot Ankle Surg 2020; 26:334-337. [PMID: 31122874 DOI: 10.1016/j.fas.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/13/2019] [Accepted: 04/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corticosteroid injections are used in the conservative treatment of Flexor hallucis longus (FHL) tendinopathy. Studies for imaging guided injection are done, however, the accuracy of blind injection has not yet been studied. PURPOSE The aim of this study was to determine the accuracy of a blind injection technique into the FHL tendon sheath. HYPOTHESIS We hypothesize that a blind injections technique into the FHL tendon sheath based on clinical examination has a high accuracy. STUDY DESIGN Descriptive cadaveric study. METHODS Ten ankles of human cadavers were blindly injected with radiologic contrast mixed with methylene blue into the FHL tendon sheath. After injection, a CT scan of each ankle was performed to evaluate the location of contrast material. CT scans were reviewed by an experienced musculoskeletal radiologist blinded to the procedure. Anatomic dissection was undertaken to assess the location of the injection fluid. RESULTS In nine ankles the radiological contrast was injected in the FHL tendon sheath. In one cadaver there was a technical problem and was therefore excluded. CONCLUSION This study shows that the FHL tendon sheath can be blindly injected based on only clinical examination with high accuracy. LEVEL OF EVIDENCE Descriptive cadaveric study.
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Chun DI, Lee HS, Won SH, Moon SI, Jung KJ, Seo JH, Cho HK, Lee DW, Ryu A, Manggala Y, Kim WJ. Closed atraumatic complete rupture of the flexor halluces longus tendon during forward lunge exercise: A case report. Medicine (Baltimore) 2019; 98:e18409. [PMID: 31852162 PMCID: PMC6922354 DOI: 10.1097/md.0000000000018409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Acute rupture of the flexor halluces longus (FHL) tendon due to trauma or laceration is a well-known phenomenon. Partial rupture of the FHL tendon caused by tendinitis or stenosing tenosynovitis is common in ballet dancers and athletes. However, atraumatic complete rupture of the FHL is rare: as of 2018, only 7 cases of closed atraumatic complete rupture of the FHL tendon have been reported in the literature. Here, we report on a patient who presented with a closed atraumatic complete rupture of the FHL tendon during a forward lunge exercise. PATIENT CONCERNS A 35-year-old female visited the clinic with pain in the plantar medial aspect of the left foot, along with weakness and loss of great toe flexion. The patient had a normal foot structure and no history of trauma or systemic disease. She performed a forward lunge exercise more than 50 times on 1 leg per day, more than once a week to strengthen her leg muscles. She reported that she felt a slight pain in her left, great toe while exercising for 3 weeks prior to her visit. One week prior to presentation, severe pain occurred suddenly when her left hallux dorsiflexed strongly during an anterior lunge exercise motion. DIAGNOSIS Magnetic resonance imaging revealed complete rupture of the FHL tendon near the level of the metatarsal head and neck junction. The lesion was prolonged, with the proximal end displaced to the metatarsal shaft region. INTERVENTIONS Complete rupture of the FHL tendon was treated with a primary suture. OUTCOMES At the 1-year follow-up, active plantar flexion of the interphalangeal joint was possible but joint function had a range of 0° to 25°. Flexion strength was reduced slightly, measuring about 70% when compared to the contralateral side, but flexion strength of the metatarsophalangeal joint was normal. LESSONS We describe an extremely rare case of complete rupture of the FHL tendon at the level of metatarsal head and neck junction. It should be understood that this injury can occur not only in professional athletes but also in the general public, and we recommend educating personal trainers on how to prevent it.
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Affiliation(s)
- Dong Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
| | - Hong Seop Lee
- Department of Foot and Ankle Surgery, Nowon Eulji Medical Center, Eulji University, Hangeulbiseok-ro, Nowon-gu, Seoul
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
| | - Sang Il Moon
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
| | - Jong Hyun Seo
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
| | - Hyung Ki Cho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
| | - Dhong Won Lee
- Department of Orthopaedic Surgery, Konkuk University Medical Center, Neungdong-ro, Gwangjin-gu, Seoul
| | - Aeli Ryu
- Department of Obstetrics and Gynecology, Soonchunhyang University Hospital Cheonan, Suncheonhyang 6-gil, Dongam-gu, Cheonan, Korea
| | - Yudha Manggala
- Department of Orthopaedic and Traumatology Surgery, Medicine Faculty, Soegijapranata Catholic University, Semarang, Indonesia
| | - Woo Jong Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
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de‐la‐Cruz‐Torres B, Barrera‐García‐Martín I, Romero‐Morales C. Comparative Effects of One‐Shot Electrical Stimulation on Performance of the Flexor Hallucis Longus Muscle in Professional Dancers: Percutaneous Versus Transcutaneous? Neuromodulation 2019; 23:865-870. [DOI: 10.1111/ner.13040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/06/2019] [Accepted: 07/31/2019] [Indexed: 11/28/2022]
Affiliation(s)
| | | | - Carlos Romero‐Morales
- Faculty of Sport Science Universidad Europea de Madrid Villaviciosa de Odón, Madrid Spain
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Abstract
The term dance encompasses a broad range of different styles; much of the orthopaedic literature has focused on ballet dancers. Injury is common in dancers at all levels, and many serious dancers sustain multiple injuries as they progress through their career. Foot and ankle injuries are among the most common injuries experienced by dancers. These injuries include those that are specific to dancers because of the unique physical maneuvers required to effectively perform, but they can also include common injuries that may require relatively different treatment because of the physical demands of the dancer. Os trigonum syndrome and flexor hallucis longus tenosynovitis generally fall into the former category as they are injuries that are more prevalent in dancers due to the extreme plantarflexion involved in dancing, especially ballet, and the relative demand placed on the toe flexors, most notably the flexor hallucis longus. On the other hand, anterior ankle impingement occurs both in dancers and in the general public. In many cases, a team approach to treatment with knowledgeable physical therapists can obviate the need for surgical treatment. If surgical treatment proves necessary, good results can be achieved with sound surgical technique and a well thought-out rehabilitation program.
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A semi-quantitative technique to assess excursion of the flexor hallucis longus. Foot Ankle Surg 2019; 25:534-537. [PMID: 30321949 DOI: 10.1016/j.fas.2018.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/11/2018] [Accepted: 04/24/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND Recent research indicates that restriction in excursion of flexor hallucis longus (FHL) contributes to hallux rigidus development. As described in the literature, clinical evaluation of FHL excursion has poor interobserver reliability. A simple, inexpensive, easily used FHL relative excursion measurement device was developed and tested. METHODS 64 subjects were enrolled with shoe size, height, weight, BMI, and age compared. Using a footplate and series of mechanical wedges, maximum ankle dorsiflexion was measured with the great toe in 15°, 30°, and 45° of dorsiflexion. RESULTS Ankle dorsiflexion decrease with progressive hallux dorsiflexion increase was statistically significant with a linear correlation (r2=.814 p<.001) and was not statistically related to shoe size, height, weight, BMI, or age. CONCLUSIONS This technique provides consistent assessment of the limitation to ankle dorsiflexion incurred by decreased FHL excursion, establishing groundwork for future studies to assess the relationship between diminished FHL excursion and FHL pathology.
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de la Cruz-Torres B, Barrera-García-Martín I, Albornoz-Cabello M. Immediate effects of ultrasound-guided percutaneous neuromodulation versus physical exercise on performance of the flexor hallucis longus muscle in professional dancers: a randomised clinical trial. Acupunct Med 2019; 37:91-97. [DOI: 10.1177/0964528419826103] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: Ultrasound-guided percutaneous neuromodulation (US-guided PNM) is a minimally invasive intervention. This technique consists of the application of percutaneous electrical stimulation (PES) through an acupuncture needle-like electrode that is placed in close proximity to the nerve or motor point of the target muscle under ultrasound guidance. Objective: To examine the immediate effects of a stretching exercise, an eccentric exercise and US-guided PNM on the performance of the flexor hallucis longus (FHL) muscle in young dancers. Methods: Randomised clinical trial. A total of 45 dancers were divided into three groups: Stretching group, Eccentric group and PNM group. The following performance parameters were assessed: range of motion (ROM) of the first metatarsophalangeal joint, balance test and unilateral heel raise fatigue test. Results: There were no differences between these groups in baseline measurements; at the end of the study, mean balance and endurance values were only significantly higher for the PNM group compared to the Stretching (p = 0.007 and p < 0.001, respectively) and Eccentric groups (p = 0.003 and p < 0.001, respectively). The effect sizes were large for the balance (d = 0.8) and endurance (d = 1.83) tests in the PNM group. Both the Stretching and Eccentric groups exhibited improvements in ROM compared to their baseline values (p = 0.009 and p = 0.004, respectively), whereas there was no significant temporal improvement noted for the PNM group. The effect sizes with respect to ROM values were moderate for stretching (d = 0.6) and eccentric (d = 0.7) exercises. Conclusion: An isolated PES intervention provides a greater immediate increase in balance and muscular strength than an active stretching and eccentric exercise of the FHL muscle in young ballet dancers.
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Anastasopoulos N, Paraskevas G, Lazaridis N, Natsis K. Reconstruction of Neglected Flexor Hallucis Longus Tendon Rupture: A Case Report. J Foot Ankle Surg 2019; 57:1256-1258. [PMID: 29937339 DOI: 10.1053/j.jfas.2018.03.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Indexed: 02/03/2023]
Abstract
Isolated rupture of the flexor hallucis longus tendon is an unusual injury. We present the case of a neglected flexor hallucis longus tendon closed traumatic rupture at the plantar aspect of the first phalangeal head of the great toe in a middle-age male. The injury occurred while he was dancing. Because end-to-end tendon suture was impossible, the ensuing gap was repaired using a free plantaris tendon graft. We present the operative repair benefit of the flexor hallucis longus tendon rupture to regain the function and strength of the interphalangeal joint of the hallux, avoid extension of the distal phalanx, and maintain the longitudinal arch of the foot.
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Affiliation(s)
- Nikolaos Anastasopoulos
- Orthopedic Surgeon and Assistant Professor, Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Paraskevas
- Associate Professor, Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Lazaridis
- Lecturer, Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Konstantinos Natsis
- Professor, Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Opdam KTM, Wiegerinck JI, van Dijk CN. Good results for treatment of flexor hallucis longus (stenosing) tenosynovitis: a systematic review. J ISAKOS 2017. [DOI: 10.1136/jisakos-2017-000151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Endoscopic All-inside Repair of the Flexor Hallucis Longus Tendon in Posterior Ankle Impingement Patients. Arthrosc Tech 2017; 6:e1829-e1835. [PMID: 29399465 PMCID: PMC5794487 DOI: 10.1016/j.eats.2017.06.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 06/29/2017] [Indexed: 02/03/2023] Open
Abstract
Longitudinal flexor hallucis longus (FHL) tendon tears are sometimes complicated by posterior ankle impingement syndrome (PAIS), especially in ballet dancers. In recent years, PAIS has been treated endoscopically, but it is difficult to suture FHL tendon tears endoscopically. In this report, we describe how to suture the FHL tendon endoscopically with the Meniscal Viper Repair system (Arthrex, Naples, FL). Without our endoscopic technique, when a patient is found to have a longitudinal tear of the FHL under endoscopy, we must choose to either neglect the tear or convert to an open repair. Open tendon suture techniques have reportedly had relatively good results but require a longer skin incision than endoscopic surgery for PAIS. Compared with the open repair, the advantages of our technique include earlier recovery, less pain, a lower rate of soft tissue complications, and improved healing through better preservation of the blood supply. This technique is an attractive and useful option because it is an easy and safe method for longitudinal FHL tendon tears.
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Lui TH. Arthroscopic Synovectomy for Zone 2 Flexor Hallucis Longus Tenosynovitis. Arthrosc Tech 2015; 4:e403-5. [PMID: 26697294 PMCID: PMC4662243 DOI: 10.1016/j.eats.2015.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 05/20/2015] [Indexed: 02/03/2023] Open
Abstract
Tenosynovitis of the flexor hallucis longus tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. It mostly involves the portion of the tendon behind the ankle joint. However, the portion of the tendon under the sustentaculum tali can also be involved. Open synovectomy requires extensive dissection. We report the technique of arthroscopic synovectomy of the deep portion of the flexor hallucis longus.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China
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Rungprai C, Tennant JN, Phisitkul P. Disorders of the Flexor Hallucis Longus and Os Trigonum. Clin Sports Med 2015; 34:741-59. [PMID: 26409593 DOI: 10.1016/j.csm.2015.06.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Os trigonum syndrome with disease of the flexor hallucis longus tendon, so-called stenosing flexor tenosynovitis, is a common cause of posterior ankle impingement. Conservative treatment is the recommended first line of treatment, with secondary treatment options of either open or arthroscopic os trigonum excision with flexor hallucis longus retinaculum release. The arthroscopic approaches have gained popularity in the past decade because of less scarring, less postoperative pain, minimal overall morbidity, and earlier return to activities. However, comprehensive understanding of the anatomy of the posterior ankle is crucial to warrant successful outcomes and minimizing complications.
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Affiliation(s)
- Chamnanni Rungprai
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, 315 Ratchawithi Road, Bangkok 10400, Thailand
| | - Joshua N Tennant
- Department of Orthopaedics, University of North Carolina School of Medicine, 3147 Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC 27514, USA
| | - Phinit Phisitkul
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
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Ribbans WJ, Ribbans HA, Cruickshank JA, Wood EV. The management of posterior ankle impingement syndrome in sport: a review. Foot Ankle Surg 2015; 21:1-10. [PMID: 25682399 DOI: 10.1016/j.fas.2014.08.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/29/2014] [Accepted: 08/11/2014] [Indexed: 02/04/2023]
Abstract
A literature review has been undertaken to assess the efficacy of management of Posterior Ankle Impingement Syndrome with an emphasis on sport. The evidence is confined to Level IV and V studies. There is a lack of prospective studies on the natural history of this condition and the outcomes of conservative treatment. Dance dominates the literature accounting for 62% of reported sports. Forty-seven papers have reported on the surgical outcomes of 905 procedures involving both open and artho-endoscopic techniques. 81% of patients required excision of osseous pathology and 42% soft-tissue problems resolving. There is a lack of standardisation of outcome reporting particularly in the open surgery group. However, the complication rates are relatively low: 3.9% for open medial, 12.7% for open lateral and 4.8% for arthro-endocopic surgery. Return to sport appears quicker for all activities in the arthro-endoscopic group but comparison of long term outcomes is more difficult with no evidence supporting superior long term results of one technique over another. Soccer players appear to return more quickly to activity than dancers.
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Affiliation(s)
- William J Ribbans
- University of Northampton, Boughton Green Road, Northampton, NN2 7AL, United Kingdom.
| | - Hannah A Ribbans
- Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
| | - James A Cruickshank
- Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
| | - Edward V Wood
- Department of Trauma and Orthopaedics, Countess of Chester Hospital, Liverpool Rd, Chester, Cheshire, CH2 1UL, United Kingdom
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The anatomic variations of the posterior talofibular ligament associated with os trigonum and pathologies of related structures. Surg Radiol Anat 2015; 37:955-62. [DOI: 10.1007/s00276-015-1428-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
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de Souza LJ, Rutledge E. Closed Rupture of the Flexor Hallucis Longus Tendon with Evaluation of the Mechanism of Injury: A Case Report. JBJS Case Connect 2014; 4:e45. [PMID: 29252349 DOI: 10.2106/jbjs.cc.m.00167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Leo J de Souza
- Department of Orthopaedic Surgery, Hennepin County Medical Center, Suite G2, 701 Park Avenue South, Minneapolis, MN 55415
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Hanna T, Dripchak P, Childress T. Chronic achilles rupture repair by allograft with bone block fixation: technique tip. Foot Ankle Int 2014; 35:168-74. [PMID: 24311740 DOI: 10.1177/1071100713514037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Timothy Hanna
- Kentucky Podiatric Residency Program, Louisville, KY, USA
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28
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Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, Kennedy JG. Posterior hindfoot arthroscopy: a review. Am J Sports Med 2014; 42:225-34. [PMID: 23868522 DOI: 10.1177/0363546513491213] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In recent years, minimally invasive surgery has developed and progressed the standard of care in orthopaedics and sports medicine. In particular, the use of posterior hindfoot arthroscopy in the treatment of posterior ankle and hindfoot injury is increasing rapidly as a means of reducing pain, infection rates, and blood loss postoperatively compared with traditional open procedures. In athletes, hindfoot arthroscopy has been used effectively in expediting rehabilitation and ultimately in minimizing the time lost from competition at previous levels. Van Dijk et al were the first to describe the original 2-portal technique, which remains the most commonly used by surgeons today and forms the basis for this review. The current evidence in the literature supports the use of 2-portal hindfoot arthroscopy as a safe, primary treatment strategy for symptoms of posterior ankle impingement, including resection of os trigonum, treatment of flexor hallucis longus and peroneal tendon injury, treatment of osteochondral lesions of the ankle, and the resection of subtalar coalitions. In this review, we present where possible an evidence-based literature review on the arthroscopic treatment of posterior ankle and hindfoot abnormalities. Causes, diagnosis, surgical technique, outcomes, and complications are each discussed in turn.
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Affiliation(s)
- Niall A Smyth
- Niall A. Smyth, Hospital for Special Surgery, 523 East 72nd Street, Ste 507, New York, NY 10021.
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Corte-Real NM, Moreira RM, Guerra-Pinto F. Arthroscopic treatment of tenosynovitis of the flexor hallucis longus tendon. Foot Ankle Int 2012. [PMID: 23199862 DOI: 10.3113/fai.2012.1108] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tenosynovitis of the flexor hallucis longus (FHL) tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. A traumatic cause for this situation, such as an ankle sprain, is considered rare. In case of failure of conservative treatment, the tendon can be surgically released, which is usually done through an open procedure. This article presents the results of an arthroscopic release of the FHL. METHODS Twenty-seven patients underwent surgery for FHL tenosynovitis over a period of 18 months. The mean age of the patients was 34 years. All patients related the onset of the condition with an ankle sprain. Eighteen patients were on worker's compensation and five had sport-related accidents. None of the patients was a professional athlete or a ballet dancer. The mean follow-up was 32 months. The outcome was measured with a satisfaction questionnaire and with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system. RESULTS The mean postoperative AOFAS score was 89 with 70% excellent or good results. Mean satisfaction rate was 4 (range, 0 to 5); 89% of the patients would undergo the procedure again. Twenty-two patients (81%) returned to the same level of activity in work and sports. A complication rate of 18% (five patients) and reoperation rate of 4% (one patient) were found. CONCLUSION Arthroscopic release of the FHL tendon was a valid procedure. It was a minimally invasive surgery that allowed good visualization of the involved structures and yielded good results. This condition can be related to trauma and is not an exclusive disease of ballet dancers or overuse.
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Purushothaman R, Karuppal R, Inassi J, Valsalan R. Hallux saltans due to flexor hallucis longus entrapment at a previously unreported site in an unskilled manual laborer: a case report. J Foot Ankle Surg 2012; 51:334-6. [PMID: 22459424 DOI: 10.1053/j.jfas.2012.02.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Indexed: 02/03/2023]
Abstract
Triggering of the big toe, or hallux saltans, is commonly due to stenosing tenosynovitis of the flexor hallucis longus at the fibro-osseous tunnel below the sustentaculum tali. It is a rare condition described mainly in female ballet dancers. This is hypothesized to be due to the en pointe position used in ballet, which puts enormous supraphysiologic loads on the flexor hallucis longus, predisposing it to injury. Trigger hallux is extremely uncommon in the general population. We are reporting a case of hallux saltans in an unskilled manual laborer, with the site of tendon entrapment just proximal to the medial malleolus in the distal leg, a hitherto unreported location of stenosis.
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Noda D, Yoshimura I, Kanazawa K, Hagio T, Naito M. Subcutaneous rupture of the flexor hallucis longus tendon: a case report. J Foot Ankle Surg 2011; 51:234-6. [PMID: 22153296 DOI: 10.1053/j.jfas.2011.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Indexed: 02/03/2023]
Abstract
It is well known that rupture of the flexor hallucis longus tendon can be associated with open injuries and that closed rupture of the flexor hallucis longus tendon is rare. Tendon injuries of the foot can occur secondary to direct, indirect, or repetitive injury. Repetitive tendon injuries can cause tendinitis or stenosing tenosynovitis. Tendinitis is associated with internal tendon injury that can present with tendon thickening, mucinoid degeneration, nodule development, or in situ partial tears. Stenosing tenosynovitis is the development of tendon adhesions within the tendon sheath that interfere with tendon gliding, known as trigger toe. The flexor hallucis longus tendon is susceptible to injury along its entire course. A total of 35 cases of complete or partial closed ruptures of the flexor hallucis longus tendon have been reported. We present the case of complete subcutaneous rupture of the flexor hallucis longus tendon associated with trauma at the proximal phalangeal head.
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Affiliation(s)
- Daisuke Noda
- Department of Orthopaedic Surgery, Fukuoka University School of Medicine, Fukuoka, Japan.
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Yammine K, Fathi Y. Ankle "sprains" during sport activities with normal radiographs: Incidence of associated bone and tendon injuries on MRI findings and its clinical impact. Foot (Edinb) 2011; 21:176-8. [PMID: 21856145 DOI: 10.1016/j.foot.2011.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/18/2011] [Accepted: 05/20/2011] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate, with magnetic resonance imaging (MRI), the occurrence of bone and tendon injuries and their impact on clinical management in athletes with ankle trauma during sports activities having normal radiographs and referred to the orthopedic department as "ankle sprains". METHODS This was a prospective study of 54 patients. Clinical examination and MR imaging were done in order to have an accurate diagnosis and the incidence of those injuries. RESULTS Nearly half of the patients were found to have no ligament injury on MRI. Isolated bone bruises and isolated tendon injuries may share the same clinical signs with ankle sprains. CONCLUSIONS MRI-based clinical management has been adjusted for each case; beside the Grade 3 ligament injuries and the rare, but difficult to diagnose osteochondral lesions of the talus, partial weight bearing or short-immobilization were offered as treatment modalities for the rest of the patients avoiding unnecessary long-term treatments and rehabilitation exercises.
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Affiliation(s)
- Kaissar Yammine
- Orthopedic Department, Emirates Hospital, Jumeirah Beach Road, Dubai 73663, United Arab Emirates.
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Porter EB, Dubois MS, Raasch WG. A 17-year-old ballet dancer with medial ankle pain. Curr Sports Med Rep 2011; 9:290-1. [PMID: 20827094 DOI: 10.1249/jsr.0b013e3181f2731e] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Emily B Porter
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
The number of females participating in sports continues to increase. Adolescent and preadolescent females are at a risk injury to both their open growth plates as well as their joints. The purpose of this article is to review the common injuries seen with the most popular sports with females. Mt Sinai J Med 77:307-314, 2010. (c) 2010 Mount Sinai School of Medicine.
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Thakur N, Leswick DA. Case of the month #167: flexor hallicus longus tendon tear distal to the master knot of Henry. Can Assoc Radiol J 2011; 62:154-7. [PMID: 21501796 DOI: 10.1016/j.carj.2009.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Revised: 12/04/2009] [Accepted: 12/11/2009] [Indexed: 11/30/2022] Open
Affiliation(s)
- Nathan Thakur
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
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Abstract
Acute injuries of the Achilles tendon are common among athletes and non-athletes alike. Injuries of other posterior calf muscles are far less common but should be considered in the differential, to ensure proper diagnosis and treatment of patients with calf injuries. This article focuses on these calf injuries, including injuries of the gastrocnemius, plantaris, soleus, and flexor hallucis longus, which may occasionally be mistaken for Achilles tendon disorders.
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Kirane YM, Michelson JD, Sharkey NA. Contribution of the flexor hallucis longus to loading of the first metatarsal and first metatarsophalangeal joint. Foot Ankle Int 2008; 29:367-77. [PMID: 18442450 DOI: 10.3113/fai.2008.0367] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A recent clinical study suggested that restrictive tenosynovitis of the flexor hallucis longus (FHL) may play an important causative role in hallux rigidus. The goals of this research were to assess normal function of the FHL and the effect of restricted FHL gliding on the loading of the hallux metatarsophalangeal joint (MTPJ). We hypothesized that proximal displacement of the FHL would increase the forces carried by the FHL tendon, causing increased loading of the first metatarsal and MTPJ. MATERIALS AND METHODS Dynamic simulations of the stance phase of walking were created by loading 5 non-embalmed, non-paired cadaver lower extremities (2 male, 3 female; mean age, 69; range, 56 to 75) in the Robotic Dynamic Activity Simulator (RDAS). The RDAS recreates lower leg motion and muscle activity based on kinematic and electromyographic data of healthy subjects. FHL tendon forces and excursions were measured for the entire stance phase of gait. Bone strains in the mid-shaft of the first metatarsal were recorded and used to derive the in situ forces and moments imposed on the metatarsal and the hallux MTPJ. RESULTS Under force-feedback control, FHL excursion averaged 6.57 (+/-3.13) mm during gait. When the FHL was held 2-, 4-, and 6-mm proximal to the mid-point of normal excursion to simulate progressive stenosis, the forces in the FHL tendon, first metatarsal and first MTP joint were progressively, and significantly, increased (p < 0.05). CONCLUSION These findings support the hypothesis that progressive fibrosis at the FHL myotendinous junction can cause increased loading of the hallux MTPJ, thereby leading to hallux rigidus.
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Affiliation(s)
- Y M Kirane
- Biomechanics Laboratory, Department of Kinesiology, Pennsylvania State University, University Park, PA, USA
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Abstract
BACKGROUND New indications for arthroscopy are being considered because arthroscopy limits incision size and potentially decreases operative morbidity. This cadaver study investigated the utility of performing an all-endoscopic flexor hallucis longus (FHL) decompression. METHODS Eight fresh-frozen cadaver legs were used. In the simulated prone position with large joint arthroscopic equipment, posterolateral and posteromedial portals were used to perform posterolateral talar process bony excision and FHL sheath debridement and release. We noted the integrity of the sural nerve, FHL tendon, and medial tibial neurovascular bundle. After open dissection, values for sural nerve distance to the posterolateral portal, the amount of FHL sheath released and the proximity of the arthroscopic instrumentation to the medial tibial neurovascular structures were recorded. RESULTS Three of eight FHL tendons were injured during the attempted FHL release. Furthermore, no FHL sheath was completely released down to the level of the sustentaculum. Although posterolateral portal placement was on average 12.1 mm from the sural nerve, it was only 6.1 mm from the lateral calcaneal branch of the sural nerve. Moreover, in all cases the medial calcaneal nerve and first branch of the lateral plantar nerve were closely juxtaposed and in some cases adherent to the FHL fibro-osseous sheath. CONCLUSIONS Although os trigonum or posterolateral talar process excision was performed without difficulty, endoscopic release of the FHL tendon proved technically demanding with significant risk to the local neurovascular structures. Given the reliability and low morbidity of open techniques, this cadaver study calls into question the clinical use of complete endoscopic FHL release to the level of the sustentaculum. Moreover, hindfoot endoscopic surgery should be performed by surgeons familiar with open posterior ankle anatomy and experienced in hindfoot endoscopy.
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Affiliation(s)
- John J Keeling
- Department of Othopaedics, Union Memorial Hospital, Baltimore, MD 21218, USA
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Sizer PS, Phelps V, James R, Matthijs O. Diagnosis and management of the painful ankle/foot part 1: clinical anatomy and pathomechanics. Pain Pract 2007; 3:238-62. [PMID: 17147674 DOI: 10.1046/j.1533-2500.2003.03029.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Distinctive anatomical features can be witnessed in the ankle/foot complex, affording specific pathological conditions. Disorders of the ankle/foot complex are multifactoral and features in both the clinical anatomy and biomechanics contribute to the development of ankle/foot pain. The superior tibiofibular, distal tibiofibular, talocrural, subtalar, and midtarsal joint systems must all participate in function of the ankle/foot complex, as each biomechanically contributes to functional movements and clinical disorders witnessed in the lower extremity. A clinician's ability to effectively evaluate, diagnose, and treat the distal lower extremity is largely reliant upon a foundational understanding of the clinical anatomy and biomechanics of this complex complex. Thus, clinicians are encouraged to consider these distinctions when examining and diagnosing disorders of the ankle/foot.
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Affiliation(s)
- Phillip S Sizer
- Texas Tech University Health Science Center, School of Allied Health, Doctorate of Science Program in Physical Therapy, Lubbock TX 79430, USA
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Mehdizade A, Adler RS. Sonographically guided flexor hallucis longus tendon sheath injection. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2007; 26:233-7. [PMID: 17255186 DOI: 10.7863/jum.2007.26.2.233] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE The purpose of this study was to describe a sonographically guided technique to perform flexor hallucis longus (FHL) tendon sheath injections. METHODS Scans were performed with an intermediate-frequency (7.5- to 12-MHz) linear transducer with the scan plane corresponding to the anatomic axial plane and the patients positioned prone. The transducer was placed along the posteromedial ankle with the needle entry point being lateral to the Achilles tendon. A 25-gauge, 1.5-in needle or a 22-gauge spinal needle was positioned directly into the tendon sheath during real-time visualization with injection of a standardized therapeutic mixture (anesthetic and long-acting corticosteroid) at the level of the posterior sulcus for the FHL. Distention of the tendon sheath during real-time visualization was considered a successful injection. RESULTS Twenty-four injections in 20 patients (12 female and 8 male; age range, 22-64 years) were performed with this technique. In each case, distention of the FHL tendon sheath was obtained as the desired end point. Apart from minor paresthesias from local anesthesia, no long-term complications from these injections have occurred to date. CONCLUSIONS We describe a method to perform sonographically guided injections of the FHL tendon sheath. Sonography provides several distinct advantages as a method to provide guidance for delivery of therapeutic injections. The most important of these is the ability to visualize the needle and make adjustments in real time to ensure that medication is delivered to the appropriate location. Given these advantages, we propose that sonographic guidance provides an excellent alternative in the administration of corticosteroids to the FHL tendon sheath.
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Affiliation(s)
- Amir Mehdizade
- Department of Radiology and Imaging, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 E 70th St, New York, NY 10021 USA
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Abstract
Although dancers develop overuse injuries common in other athletes, they are also susceptible to unique injuries. This article reviews common foot and ankle problems seen in dancers and provides some basic diagnosis and treatment strategies.
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Affiliation(s)
- Nancy J Kadel
- Department of Orthopaedics and Sports Medicine, University of Washington, Box 356500, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.
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Reconstruction of Chronic Achilles Tendon Disorders with Achilles Tendon Allograft. TECHNIQUES IN FOOT AND ANKLE SURGERY 2005. [DOI: 10.1097/01.btf.0000177228.45213.5d] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Na JB, Bergman AG, Oloff LM, Beaulieu CF. The Flexor Hallucis Longus: Tenographic Technique and Correlation of Imaging Findings with Surgery in 39 Ankles. Radiology 2005; 236:974-82. [PMID: 16118172 DOI: 10.1148/radiol.2362040835] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine the use of tenography for evaluation of the flexor hallucis longus (FHL) sheath. MATERIALS AND METHODS Institutional review board approval was waived, patient consent was obtained, and the study was HIPAA compliant. Retrospective review of 192 FHL tenograms and associated surgical records identified 39 ankles in 37 patients (17 male, 20 female; mean age +/- standard deviation, 38 years +/- 13.8; range, 14-68 years) in which both tenography and surgery had been performed. Two radiologists reviewed tenographic findings, including contrast agent extravasation, synovial irregularity, stenosis, fibrous bands, sheath outpouching, extent of opacification, and communications with adjacent structures. Alterations in pain after anesthesia of the tendon sheath were also recorded. Surgical reports were reviewed. RESULTS Thirty-four of 39 tenograms were diagnostic. Some extravasation occurred in nine (45%) of 20 injections with an initial injection method and in two (11%) of 19 with a new injection technique. Synovial irregularity was present in all 34 studies (15 mild, 16 moderate, three severe). Stenoses were identified in 23 (68%) of 34 ankles, fibrous bands were seen in 16 (47%) of 34 ankles, and outpouching of the sheath above a stenosis was present in 13 (38%) of 34 ankles. Communication of the FHL sheath with the ankle, flexor digitorum longus, or subtalar joint occurred in half the cases. Most patients with pain reported relief; relief was complete (100% reduction from preprocedural pain) in eight of 27, moderate (50%-90% reduction) in nine of 27, and mild (<50% reduction) in eight of 27 patients. CONCLUSION Tenography of the FHL sheath produced diagnostic images in almost all patients and effectively demonstrated abnormalities of the tendon sheath. Pain relief with anesthetic injection helped confirm the FHL sheath as the pain generator.
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Affiliation(s)
- Jae-Boem Na
- Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr, S-056, Stanford, CA, 94305-5105, USA
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Michelson J, Dunn L. Tenosynovitis of the flexor hallucis longus: a clinical study of the spectrum of presentation and treatment. Foot Ankle Int 2005; 26:291-303. [PMID: 15829213 DOI: 10.1177/107110070502600405] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Symptoms associated with flexor hallucis longus (FHL) pathology can manifest themselves anywhere along its length from the posterior leg to the plantar foot and the hallux. This study describes the spectrum of clinical presentations seen with FHL pathology, illustrates the relevant physical examination findings, and outlines a treatment approach. MATERIALS Computerized medical data was prospectively collected on 81 patients treated between January, 1997 and March, 2002. The 55 females and 26 males had an average age of 38.3 years, with a mean follow-up of 21.3 months. Forty-five of 81 had previous therapy that failed, usually for "plantar fasciitis." Twenty-seven were active athletically and 24 related the onset of symptoms to a specific traumatic episode. Pain was located at the posteromedial ankle in 40, plantar heel in 23, plantar midfoot in 22, and multiple locations in 16. All patients had tenderness of the FHL. Restriction of FHL excursion was demonstrated in 30 patients by limited hallux metatarsophalangeal joint dorsiflexion when the ankle was dorsiflexed ("FHL stretch test"). Thirty-four patients had magnetic resonance imaging of the FHL, 28 (82%) of which were positive for synovitis of the FHL. Treatment included an FHL stretching program, short-term immobilization, and operative decompression and synovectomy in patients for whom nonoperative treatment failed. RESULTS Of the 58 patients treated nonoperatively, 37 (64%) had successful results. Twenty-three patients had surgery, 20 at the posterior ankle fibro-osseous tunnel, and three in the sesamoid region. All patients treated operatively had successful outcomes. A subset of 10 patients had hallux rigidus symptoms without significant osteophyte formation. All 10 obtained successful results with treatment directed at restoring normal FHL excursion (nine nonoperatively, one by FHL release). This suggests that limited FHL excursion may be an etiology for the development of hallux rigidus. CONCLUSIONS Clinical syndromes related to the FHL are more frequent than previously reported. The close relationship of the FHL to commonly injured structures (such as the plantar fascia) contributes to significant delays in effective treatment.
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Affiliation(s)
- James Michelson
- Department of Orthopaedics, University of Vermont, Stafford 428B, Burlington, VT 05405, USA.
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Leffler S, Disler DG. MR imaging of tendon, ligament, and osseous abnormalities of the ankle and hindfoot. Radiol Clin North Am 2002; 40:1147-70. [PMID: 12462474 DOI: 10.1016/s0033-8389(02)00052-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article serves as an overview of the pathologic processes that are seen in the foot and ankle. MRI can play a pivotal role in making precise diagnoses and then guiding treatment decisions. MRI can be extremely helpful in determining response to therapy.
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Affiliation(s)
- Susan Leffler
- Commonwealth Radiology, PC, 5801 Bremo Road, Richmond, VA 23226, USA.
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Abstract
The Flexor Hallucis Syndrome has been associated with ballet and sports activities. It has been thought to represent over use with attendant tenosynovitis of the tendon in the fibro-osseous tunnel extending from the ankle to the midfoot. We report a patient with an accessory flexor digitorum longus who presented with classical clinical features of the syndrome. The patient's disabling symptoms persisted despite a year and a half of nonoperative treatment. They were finally relieved when the accessory muscle was excised. In addition to the previously described clinical features of the Flexor Hallucis Syndrome, the physical exam included abnormal fullness between the Achilles tendon and the tibia. When the ankle was held in dorsiflexion, there was limited dorsiflexion of the lateral toes, which were tethered by the "cork-in-a-bottle" effect of the distal muscle mass of the accessory flexor digitorum longus muscle at the flexor retinaculum and fibro-osseous canal of the flexor hallucis longus. The MRI examination confirmed the presence of an abnormal muscle mass extending distal to the ankle joint with the foot in neutral. The study also demonstrated fluid in the ankle joint and fibro-osseous canal of the flexor hallucis, and marrow edema within the body of the talus consistent with chronic inflammation. Follow-up MRI six months after excision of the muscle revealed some scar formation at the site of the previously excised muscle and complete resolution of the joint effusion, fluid in the tunnel of the flexor hallucis, and marrow edema.
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