? FHL tendinopathy +/- Os Trigonum Syndrome

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Hi all,

Pt has been running solid 3days/wk for 6 months, and has been building up from 5km runs all the way up to 23km (which he has plateaued for the past 3wks). Pt also does football (AFL) training x 2 and doing weighted squats and dead lifts in the gym x 3 (+ upper body exercises).

- Pt Complaining of pain around posterior medial malleolus and a shooting pain along 1st ray during running and active and resisted plantarflexion of AJ and 1st mtpj. This pain started 3/52 ago seems to flare up most after football training...pain subsides after an agonizing 45min of run/training.

- Pt has mentioned an occasional sharp debilitating pain in posterior ankle caused by a sudden change in direction or stopping motion when the foot is in a platarflexed position, and when strikes the ball too far distally when kicking (ie not in the sweet spot of the foot)- passive PF reproduces this at end range--> this pain has been present for as long as pt can remember( to varying degrees), however it is currently more painful than usual.

- other obs: There is some swelling present both posterior to medial mal. and anterior ankle. reduced AJ dorsiflexion (end of range has been described as osseus by pt)

- notes: Pt has previously had an x- ray for a lateral ankle sprain 2yrs ago, pt recalls a physiotherapist casually mentioning an accessory bone in his foot when looking at the x-ray --> i have asked him to dig up the x-ray particularly the lateral view to get a little more insight as to whether an os trigonum is present.

I am thinking FHL tendinopathy/tensosynovitis is associated with the 1st dot point and an Os trigonum the cause of the 2nd dot point (especially if old xray is +ve for os trigonum).

Currently: I have advised pt RICE medial mal., NSAIDs, reduce activity (avoid kicking and agility work, 50% running load if pain tolerable), and attempt some gastroc stretching to improve rom.

Current plan going forward:
Short term: rice, nsaids, heel lift and a reduced activity.
Mid term: If no improvement refer to sport dr for potential cortisone injections/ further imaging to confirm structures involved.
Long term: ? a surgical consult for Os Trigonum resection
I am finding it hard to find info on treating FHL tendinopathy seems predominately a ballet injury and the info seems to be quite vague, as is os trigonum syndrome.

1) How do you normally treat FHL tendinopathy and Os trigonum syndrome?
2) How likely are the two issues related?
3) How would low dye taping effect the load on the FHL tendon?
4) Is a heel lift a good idea?
5) Any other ideas as to how to progress from here? what would your next move be?

If you could answer any of the above questions it will be very helpful.

Pt will be very reluctant to completely cease activity/miss games and will most likely attempt to play through the pain as he gets $$$ for matches and needs to cement his spot in the team. So before I 'experiment' too much with solutions I thought I would consult my peers.

Cheers!

 

Hi mgrig,

Hard to give advice without a diagnosis but lets work with what we know at the present time.

Firstly is the pain unilateral or bilateral? I couldn't see this mentioned in your post.

What did you find with your assessments? How was his walking / running mechanics, Jack's test, resupination resistance, lunge test??

What standard of Aussie Rules is he playing? What position does he play? Pain started 3 weeks ago, we are at the stage of the pre-season where training is tailored to be more match focused so if he is a key position player / ruckman he may have increased his jump training.. increased probability of reaching extreme ankle plantarflexion range of motion (os trigonum symptoms) and/or increased tensile strain to the flxor hallucis longus, flexor digitorum longus and tib post tendons as they provide STJ supination moments and ankle plantarflexion moments (just a thought). Has his training changed recently?

In terms of management, your short term plan is sound. Add to this further diagnostics (ultrasound / MRI) of the ankle. So to answer Question 5, diagnostics!
Considering injection already? This sounds mechanical so how do you think he would respond to orthosis? This comes back to your assessment. Some more info on the patient, some diagnostics and we can work through a possible orthotic prescription.

I can't answer whether taping would help until we know more about his mechanics. You mentioned what appears to be a bony ankle equinus. Heel lifts will help in these cases, calf stetching not so much. Maybe some ankle joint mobilisations / manipulations are warranted.

More info on what you found with your biomechanical assessments would be great.

Cheers, Tim

 

A couple of quick points.
Certainly FHL tendinopathy and a os trigonum can be interrelated as they lie very close to each other. Inflammation of one can affect the other.
I would be seeing clarification if there is an actual os trigonum or whether it may be soft tissue entrapment- similar management, but would may the clinical decision making easier. Perhaps getting a Sports Physician's involvement would be valuable.
I would try low- dye taping certainly, but the heel lift may irritate any posterior impingement.
Low-dye can be very effective at offloading both structures without lifting the heel, and can give a good idea of the mechanism of the pathology.