summary FHL Tendonitis & Injuries occur as a result of impingement of the flexor hallucis longus tendon with resultant tendonitis and even tendon rupture along the posterior ankle joint. Diagnosis can be made clinically with posterolateral ankle pain and pain with resisted flexion of the hallux IP joint. MRI studies may show tenosynovitis of the tendon. Treatment is generally rest, activity modifications and NSAIDs. Surgical management is indicated for acute FHL tendon laceration and progressive tendonitis that fails nonoperative management. Epidemiology Anatomic location posterior ankle great toe Risk factors excessive plantar-flexion dancers in on pointe position gymnasts Etiology 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
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 2824 FIGURES: A Type & Select Correct Answer 1 posterior tibial tendon 3% (75/2423) 2 extensor hallucis longus tendon 2% (45/2423) 3 flexor hallucis longus tendon 94% (2279/2423) 4 tibial nerve 0% (10/2423) 5 anterior tibial tendon 0% (2/2423) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07SM.33) A 24-year-old dancer reports posterior ankle pain when in the âen pointeâ 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? QID: 8695 Type & Select Correct Answer 1 Painful os trigonum 21% (126/604) 2 Posterior ankle soft-tissue impingement 4% (22/604) 3 Stricture in the knot of Henry 2% (14/604) 4 Flexor digitorum longus tendinitis 3% (20/604) 5 Flexor hallucis longus tendinitis 70% (421/604) L 1 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 1418 FIGURES: A Type & Select Correct Answer 1 Reproduction of pain with percussion of the posterior tibial nerve 3% (54/2153) 2 Painful crepitus of tendon with passive motion at great toe 69% (1479/2153) 3 Posterior ankle pain with forced passive plantar flexion 16% (336/2153) 4 Medial ankle pain with resisted inversion 12% (265/2153) 5 Foot drop with weakness of dorsiflexion 0% (4/2153) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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? QID: 1164 Type & Select Correct Answer 1 Decompression of the flexor hallucis longus at the level of the ankle 90% (2967/3281) 2 Decompression of the flexor hallucis longus at the level of the metatarsal 7% (219/3281) 3 Decompression of the peroneal tendons at the level of the ankle 1% (49/3281) 4 First metatarsal osteotomy 1% (30/3281) 5 Gastrocnemius recession 0% (8/3281) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
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