Tenosynovitis of the Flexor Hallucis Longus: A Clinical Study of the Spectrum of Presentation and Treatment

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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References

1. Baxter

: The foot in running, in Mann

Coughlin

(eds.), Surgery of the Foot and Ankle, 7th ed. St. Louis, Mosby, 1999.

2. Bingold

Collins

: Hallux rigidus, J. Bone Joint Surg. 32B:214–222, 1950.

3. Bonney

Macnab

: Hallux valgus and hallux rigidus, J. Bone Joint Surg. 34B:366–385, 1952.

4. Boruta

Beauperthuy

: Partial tear of the flexor hallucis longus at the knot of Henry: presentation of three cases. Foot Ankle Int. 18:243–246, 1997.

5. Carr

: Complications of calcaneus fractures entrapment of the flexor hallucis longus: report of two cases, J. Orthop. Trauma 4:166–168, 1990.

6. Cooper

Wolin

: Os trigonum syndrome with flexor hallucis longus tenosynovitis in a professional football referee, Med. Sci. Sports Exerc. 31:S493–S496, 1999.

7. Ferris

Sharkey

Smith

Matthews

: Influence of extrinsic plantar flexors on forefoot loading during heel rise. Foot Ankle Int. 16:464–473, 1995.

8. Gould

Schneider

Ashikaga

: Epidemiological survey of foot problems in the continental United States, 1978–1979. Foot Ankle, 1:8–10, 1980.

8. Gould

: Stenosing tenosynovitis of the flexor hallucis longus tendon at the great toe. Foot Ankle 2:46–48, 1981.

10.

9. Hamilton

Chao

: Posterior Ankle Pain in Athletes and Dancers. Foot Ankle Clin. 4:811–832. 1999.

11.

10. Hamilton

: Stenosing tenosynovitis of the flexor hallucis longus tendon and posterior impingement upon the os trigonum in ballet dancers. Foot Ankle 3:74–80, 1982.

12.

11. Hamilton

: Foot and ankle injuries in dancers, Clin. in Sports Med. 7:143–173, 1988.

13.

12. Hamilton

Geppert

Thompson

: Pain in the posterior aspect of the ankle in dancers. Differential diagnosis and operative treatment, J. Bone Joint Surg. 78A:1491–1500, 1996.

14.

13. Hardaker

Jr Margello

Goldner

: Foot and ankle injuries in theatrical dancers, Foot Ankle 6:59–69, 1985.

15.

14. Hattrup

Johnson

: Subjective results of hallux rigidus following treatment with cheilectomy, Clin. Orthop.: 182–191, 1988.

16.

15. Hedrick

McBryde

: Posterior ankle impingement, Foot Ankle Int. 15:2–8, 1994.

17.

16. Heller

Brage

: The effects of cheilectomy on dorsiflexion of the first metatarsophalangeal joint. Foot Ankle Int. 18:803–808, 1997.

18.

17. Hintermann

Nigg

Sommer

: Foot movement and tendon excursion: an in vitro study, Foot Ankle Int. 15:386–395, 1994.

19.

18. Horton

Park

Myerson

: Role of metatarsus primus elevatus in the pathogenesis of hallux rigidus, Foot Ankle Int. 20:777–780, 1999.

20.

19. Inokuchi

Usami

: Closed complete rupture of the flexor hallucis longus tendon at the groove of the talus, Foot Ankle Int. 18:47–49, 1997.

21.

20. Kitaoka

Alexander

Adelaar

: Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 15:349–353, 1994.

22.

21. Klein

Mattys

Rooze

: Moment arm length variations of selected muscles acting on talocrural and subtalar joints during movement: an in vitro study, J. Biomech. 29:21–30, 1996.

23.

22. Kolettis

Micheli

Klein

: Release of the flexor hallucis longus tendon in ballet dancers, J. Bone Joint Surg. 78A:1386–1390, 1996.

24.

23. Leitschuh

Zimmerman

Uhorchak

Arciero

Bowser

: Hallux flexion deformity secondary to entrapment of the flexor hallucis longus tendon after fibular fracture, Foot Ankle Int. 16:232–235, 1995.

25.

24. Mann

Clanton

: Hallux rigidus: treatment by cheilectomy, J. Bone Joint Surg. 70A:400–406, 1988.

26.

25. Mann

Coughlin

: Surgery of the Foot and Ankle, New York, Mosby, 1999.

27.

26. Marotta

Micheli

: Os trigonum impingement in dancers, Am. J. Sports Med. 20:533–536, 1992.

28.

27. McCarroll

Ritter

Becker

: Triggering of the great toe. A case report. Clin. Orthop. 175:184–185, 1983.

29.

28. McMaster

: The pathogenesis of hallux rigidus, J. Bone Joint Surg. 60B:82–87, 1978.

30.

29. Romash

: Closed rupture of the flexor hallucis longus tendon in a long distance runner: report of a case and review of the literature, Foot Ankle Int. 15:433–436, 1994.

31.

30. Sammarco

Cooper

: Flexor hallucis longus tendon injury in dancers and nondancers. Foot Ankle Int. 19:356–362, 1998.

32.

31. Sarrafian

: Anatomy of the Foot and Ankle. New York, J.B. Lippencott Co., 1983.

33.

32. Shereff

Bejjani

Kummer

: Kinematics of the first metatarsophalangeal joint. J. Bone Joint Surg. 68A:392–398, 1986.

34.

33. Solomon

Brown

Gerbino

Micheli

: The young dancer. Clin. Sports Med. 19:717–739, 2000.

35.

34. Spoor

van Leeuwen

Meskers

Titulaer

Huson

: Estimation of instantaneous moment arms of lower-leg muscles, J. Biomech. 23:1247–1259, 1990.

36.

35. Theodore

Kolettis

Micheli

: Tenosynovitis of the flexor hallucis longus in a long-distance runner, Med. Sci. Sports Exerc. 28:277–279, 1996.

37.

36. Trepman

Mizel

Newberg

: Partial rupture of the flexor hallucis longus tendon in a tennis player: a case report, Foot Ankle Int. 16:227–231, 1995.

38.

37. Wei

Kneeland

Okereke

: Complete atraumatic rupture of the flexor hallucis longus tendon: a case report and review of the literature. Foot Ankle Int. 19:472–474, 1998.