Updated: 3/2/2019

FHL Tendonitis & Injuries

Topic
Review Topic
0
0
Questions
5
0
0
Evidence
2
0
0
https://upload.orthobullets.com/topic/7024/images/fhlteno_sag.jpg
https://upload.orthobullets.com/topic/7024/images/fhllacerationsag2.jpg
https://upload.orthobullets.com/topic/7024/images/fhllacerationaxial.jpg
https://upload.orthobullets.com/topic/7024/images/fhllacerationsag.jpg
Introduction
  • Impingement of the flexor hallucis longus with resultant tendonitis and even rupture can occur at the level of the posterior ankle joint
  • Epidemiology
    • location
      • posterior ankle 
      • great toe
    • risk factors
      • excessive plantar-flexion
        • dancers in on pointe position
        • gymnasts
  • Pathophysiology
    • mechanism of injury
      • activities involving maximal plantar-flexion
    • pathoanatomy
      • posterior to the talus
      • within the fibro-osseous tunnel
        • in chronic cases nodule formation may lead to triggering
  • Associated conditions
    • posterior ankle impingement
    • os trigonum (posterolateral tubercle)
Anatomy
  • Muscle
    • FHL
      • originates from posterior fibula
      • travels between posteromedial/posterolateral tubercles of the talus
      • contained within fibro-osseous tunnel
      • passes beneath the sustentaculum tali
      • crosses dorsal to FDL (at the Knot of Henry) 
        • FHL is "higher" at Knot of Henry
        • FDL is "down" at Knot of Henry
      • multiple connections exist between the FDL and FHL
      • distally it stays dorsal to the FDL and neurovascular bundle
      • inserts on the distal phalanx of the great toe
  • Biomechanics
    • primary action
      • plantarflexion of the hallux IP and MP joints
    • secondary action
      • plantarflexion of the ankle 
Presentation
  • Symptoms
    • posteromedial ankle pain 
    • great toe locking with active range of motion
    • crepitus along the posterior medial ankle 
  • Physical exam 
    • pain with resisted flexion of the IP joint
    • pain with forced plantarflexion of the ankle
    • motion
      • great toe triggering with active or passive motion but no tenderness at the level of the first metatarsal head
Imaging
  • MRI 
    • findings
      • fluid around the tendon at level of ankle joint
      • intra-substance tendinous signal 
Differentials
  • Os trigonum syndrome
    • pain is posterolateral in os trigonum syndrome
Treatment
  • Nonoperative
    • rest/activity modification, NSAIDS
      • indications
        • first line of treatment
      • modalities
        • arch supports
        • physical therapy
  • Operative
    • release of the FHL from the fibro-osseous tunnel, tenosynovectomy, possible tendinous repair  
      • indications
        • recalcitrant symptoms
        • in athletes when symptoms persist despite rest and nonsurgical management
      • technique
        • approach
          • arthroscopic
          • open, posteromedial
FHL Laceration
  • Introduction
    • direct trauma to the FHL tendon in an acute setting
  • Pathophysiology
    • mechanism of injury
      • acute laceration
        • most common form of injury
  • Presentation
    • physical exam
      • range of motion
        • loss of active interphalangeal joint flexion
  • Imaging
    • MRI  
      • findings
        • tendon ends may be retracted 
  • Treatment
    • operative 
      • acute surgical repair of the laceration 
        • indications
          • lacerations of both the FHL and the FHB 
 

Please rate topic.

Average 4.1 of 32 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (5)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(OBQ09.11) A 30-year-old ballet dancer complains of snapping and pain behind the medial malleolus, as well as triggering of her great toe. MRI scan is shown in figure A. What antatomic structure is being impinged at the level of the posterior ankle joint? Review Topic

QID: 2824
FIGURES:
1

posterior tibial tendon

3%

(63/2075)

2

extensor hallucis longus tendon

2%

(40/2075)

3

flexor hallucis longus tendon

94%

(1951/2075)

4

tibial nerve

0%

(8/2075)

5

anterior tibial tendon

0%

(0/2075)

L 1

Select Answer to see Preferred Response

SUBMIT RESPONSE 3

You have 100% on this question.
Just skip this one for now.

(SAE07SM.33) A 24-year-old dancer reports posterior ankle pain when in the “en pointe” position. Examination reveals posteromedial tenderness, no pain reproduction with passive forced planter flexion, and pain with motion of the hallux. What is the most likely diagnosis? Review Topic

QID: 8695
1

Painful os trigonum

21%

(46/223)

2

Posterior ankle soft-tissue impingement

4%

(8/223)

3

Stricture in the knot of Henry

2%

(5/223)

4

Flexor digitorum longus tendinitis

2%

(4/223)

5

Flexor hallucis longus tendinitis

70%

(156/223)

L 1

Select Answer to see Preferred Response

SUBMIT RESPONSE 5

You have 100% on this question.
Just skip this one for now.

(SBQ07SM.33) A 32-year-old dancer presents with right-sided posteromedial ankle pain. Her symptoms worsen during the "demi-pointe" position. MRI scan is shown in Figure A. Which of the following physical exam findings is most consistent with this diagnosis? Review Topic

QID: 1418
FIGURES:
1

Reproduction of pain with percussion of the posterior tibial nerve

2%

(41/1734)

2

Painful crepitus of tendon with passive motion at great toe

71%

(1225/1734)

3

Posterior ankle pain with forced passive plantar flexion

14%

(236/1734)

4

Medial ankle pain with resisted inversion

12%

(215/1734)

5

Foot drop with weakness of dorsiflexion

0%

(3/1734)

L 2

Select Answer to see Preferred Response

SUBMIT RESPONSE 2

You have 100% on this question.
Just skip this one for now.

(OBQ04.59) A 23-year-old professional ballet dancer complains of medial ankle pain when in the en pointe position. Physical exam shows a hyper-mobile ankle with palpable crepitus along the medial ankle with active range of motion of the great toe. Six months of nonoperative management including rest, ice, NSAIDs, and arch support have failed to provide relief. What is the best next step in management? Review Topic

QID: 1164
1

Decompression of the flexor hallucis longus at the level of the ankle

90%

(2265/2516)

2

Decompression of the flexor hallucis longus at the level of the metatarsal

7%

(168/2516)

3

Decompression of the peroneal tendons at the level of the ankle

1%

(37/2516)

4

First metatarsal osteotomy

1%

(28/2516)

5

Gastrocnemius recession

0%

(7/2516)

L 2

Select Answer to see Preferred Response

SUBMIT RESPONSE 1
ARTICLES (5)
Topic COMMENTS (2)
Private Note