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Updated: Nov 2 2022

FHL Tendonitis & Injuries


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  • 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 posteromedial 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
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