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Flexor Hallucis Longus tendonitis

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Greguar, Mar 12, 2009.

  1. Greguar

    Greguar Member

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    suspected tendonitis of the flexor hallucis longus tendon. Mri scan reveals no tears/abnormalities.
    Pain is felt around sesamoid area(just before mainly), and patients experience jamming and clicking of his great toe.
    i have suggested ice/heat as well as rest. I was wondering what the main methods of treatment were preferably conservative but also if surgery was successfull in this sort of case. help much appreciated, Greg.
  2. Greguar

    Greguar Member

    Also will stretching of the flexor hallucis longus muscle be beneficial?
  3. Griff

    Griff Moderator

    Are you saying that the MRI showed absolutely no FHL pathology? If so why the suspected tendinopathy?
  4. Greguar

    Greguar Member

    i did not order the MRI myself, and am aware they do not always pick up all problems with tendons, as i have read on many websites too. i can however see and feel a tight tendon, and along with the patients description clearly indicates flexor hallucis longus pathology.
  5. Griff

    Griff Moderator

    Ok, so assuming it is an FHL issue - what was the mechanism of injury/what is the aetiological cause of pathological force within this structure?
  6. Greguar

    Greguar Member

    Last edited by a moderator: Mar 12, 2009
  7. Griff

    Griff Moderator

    Hi again Greguar,

    Thanks for the link - are you saying you think your patient has an FHL fissure? As this article seems to suggest that in these cases pain is more often in the sub-navicular region.

    Maybe some more clinical information about your patient would help

  8. Greguar

    Greguar Member

    i am aware of the different locations; however am sure a a fissure can occur further along the tendon. thanks
  9. Greguar

    Greguar Member

    a fissure is just another name for a tear isn't it? surely if an mri is incapable of picking a tear up in the sub-nacicular region then it is equally likely too along the course of the tendon, be it at the start or end. thanks in advance.
  10. Griff

    Griff Moderator


    Maybe a step back should be taken - why dont you post up more information for all of us. Your full subjective and objective history taking may help - pt age, weight, occupation/activity levels, foot type/morphology, dynamic weight bearing observations etc etc


  11. drsarbes

    drsarbes Well-Known Member

    Mind if I join in?

    First; tendon tears are sometimes missed by MRI depending on the severity, type, concomitant pathology and which tendon you are looking at. For instance, a small linear peroneal tear is missed more often then it is seen. This is mainly due to the multi plane course. The FHL, plantarly at least, is failry straight and as a consequence any pathology would be hard to hide on MRI.

    Secondly, pain at the sesamoid with "clicking" and no evidence of tendon pathology on MRI would lead me to consider a sesamoid etiology rather then an isolated FHL tear.

    The link that was suggested, as far as I can tell, was for proximal tendon derangement, not forefoot pain.

    What is the history on this patient? Any trauma? Foot type? Age? Sex? occupation?

  12. Griff

    Griff Moderator

    Hi Steve,

    Hell no! This conversation was fast becoming surgical (whether appropriately or not) so your input is far superior to mine. Thanks for the information.

    Hopefully Greguar will post some more clinical information for us

  13. Greguar

    Greguar Member

    subject has experienced pain for over a year now; initially diagnosed with plantar fasciitis and provided with custom orthotics and non custom ones to no avail. He believes he may have hyper-extended his big toe playing basketball which was shortly after recovering from a fractured fibula at its base. he is 20 years of age and is otherwise fit and healthy and practiced sports daily before injuring his fibula. one thing i did notice was little fatty pad cushioning on the affected sesamoid area, but does not have a fracture of the area and i preseume the mri came back negative for these bones too. my patient does not descrobe pain over the sesamoid region however; and told me that some arch pads aggrevate the upper arch/sesamoid area tendons when placed against it. visibly there is a tight structure that seems pronounced and tight on flexion. the clicking of the big toe and jamming sensation was what led me to thinking it was the fhl tendon.
  14. drsarbes

    drsarbes Well-Known Member

    Hi Greguar:

    " the clicking of the big toe and jamming sensation was what led me to thinking it was the fhl tendon" ------
    Fair enough. Have you felt or heard the click yourself or is this something your patient feels. Have you identified the location of this click (sesamoid joint, MTPJ, flexor tendon)? If his MRI weren't normal I might suggest an OCD given his history of jamming his hallux.

    Interesting history note of fibular "base" fracture. Was this ipsilateral? Have you evaluated him for any possible common peroneal nerve damage? This might account for his symptoms.

    One more question if I may; if you have done AP (DP) X-Rays, are the sesamoid position normal?
    Sometimes when there is a flexor tear or weakness the medial (or lateral) sesamoid will retract slightly.

  15. I-pod

    I-pod Active Member

    yes the fracture was on the same side. nerve tests came back negative. sesamoid position seems normal; lateral sesamoid slightly lower however.
    i have personally heard the clicking which sounds i feel is originating from the 1mtp joint.
    This case has really stumped me, as i fully expected the MRI scan to reveal any abnormalities. thanks for your expert help!
  16. I-pod

    I-pod Active Member

    we are talking a mm lower for the lateral sesamoid location
  17. efuller

    efuller MVP

    Well, with the clinical description above, I'm reminded of the old quote from one of my professors. If you hear hoofbeats don't think of zebras.

    What do people think are the most common causes of pain at the sesamoids? High ground reaction force is at the top of my list. Is there a hole in the sock liner under the first metatarsal head? Is there significant callus under the first metatarsal head. If there isn't then it would have been very helpful to mention this in the initial description. Is there a prominent plantar fascia?


  18. David Smith

    David Smith Well-Known Member

  19. Greguar

    Greguar Member

    Thanks for the responses guys. Eric what you have said seems to have hit the nail very firmly on its head. there is indeed a prominent platar fascia, and wear of the sock liner arounf the sesamoid area. What do u suggest now as best treatment method.( i will thank-you officially to make it 20)
  20. Greguar

    Greguar Member

    however Eric, we have already tried the classic dohnut pad around the sesamoid region but this actually pressed against the tendon just prior to the sesamoids. Any suggestions? Thanks a lot, xx
  21. Greguar

    Greguar Member

    Also if it was flexor hallucis longus tendonitis, couldnt a fallen arch due to this cause extra pressure on the sesamoid region? the patient dpes not complain of sesamoid pain but more so of the joint and tendon prior to the sesamoids.
  22. efuller

    efuller MVP

    Regardless of the diagnosis, if it is caused by high pressure at that location, then you should reduce the pressure at that location. I usually prefer a reverse Morton's extension. (A piece of 1/8" korex [cork] under metatarsal heads 2-5. This can be placed under a sock liner or under an orthotic extension.

    You could also test the location of the STJ axis. Feet with medially deviated STJ axes will pronate because of ground reaction force. The pronation, if enough eversion range of motion is available, will cause high loads sub 1. These feet should be helped with a rearfoot varus wedge or medial heel skive.

    A foot with a laterally deviated STJ axis will be laterally unstable and will pronate because of muscle activity. The peroneus longus especially caused increased force under the first met head. A rearfoot varus wedge will not help this foot.


  23. Greguar

    Greguar Member

    good info eric. i was wondering what your view would be on a forefoot varus wedge. Again help much appreciated! cheers
  24. efuller

    efuller MVP

    With the assumption that high forces under the first met caused the symptoms, then I would not use a forefoot varus wedge to try and relieve the symptoms. In a foot with a medially positioned STJ axis, the first met head is still on the pronation side of the axis. You can verify this with the patient in the chair and their fee toward you. If the patient stands, maximally pronated, maximally pronate the STJ and push up on the first metarsal head. In the medially deviated STJ axis foot the fore on the first met head will tend to make the foot pronate. A forefoot varus wedge will tend to shift the center of pressure more medial which will tend to decrease the overall pronation moment, but it will tend to increase the force on the first metatarsal. This is what caused the problem in the first place.


  25. Greguar

    Greguar Member

    Are you saying that even if a patient has forefoot varus; you would still use a rearfoot varus wedge? Thanks again!
  26. Greguar

    Greguar Member

    i believe there is more forefoot varus than rearfoot.
    i am beginning to wonder how these abnormalities in stj and metatarsals came about after the fractured fib. i believe the fallen arch/pronation may be a result of arch muscle wastage? Any ideas?
  27. efuller

    efuller MVP

    I don't use the STJ neutral classification any more, because it does not help me predict what kind of treatment that I should use. I go more by where the load /callus is. Fore example, you could measure a forfefoot varus and the medial forefoot may or may not bear a lot of weight depending on whether there is enough range of motion to get the medial forefoot to the ground. If there is insufficient eversion available, I will use a forefoot varus wedge. On the other hand if you measure a forefoot varus and there is already a lot of force on the first met head, you may not help the situation with a forefoot varus wedge.

    I feel that forefoot to rearfoot measurement is not accurately repeatable. The first two reasons that come to mind is the inability to reproduce the heel bisection and the difference in loading of the fifth ray when the measurment is taken. (if you push harder, you will get more forefoot valgus.) That said, if there is prolonged high forces on the medial forefoot I would expect a decrease in medial arch height (increase in forefoot varus) over time.

    If you lost the medial foot intrinsics I would expect a decrease in medial arch height as well as there would only be passive structures resisting dorsiflexion of the medial forefoot. However, it would be possible to loose medial arch height in the presence of strong intrinsics if there was high load on the medial forefoot.


  28. musmed

    musmed Active Member

    Dear All
    Lets do something very simple.
    Get an ultrasound performed with the sound unit turned up,
    go looking for the sound
    see what is happening when the sound occurs
    and bingo

    Commonly you will see the fl.hall. longus tendon pulling against the lateral sesamoid with bunching of the FHLongus tendon as it passes through the gap between the sesamoids.
    Seen it a few times.

    Using the Travell and Simon's spray and stretch technique basically using ethyl chloride or something that makes a cold spray,
    start at the origin of the muscle behind the fibula to the sole of the foot to the great toes
    sit side on to the foot,
    then grasp the great toe with one hand and the dorsum of the ankle with the other
    extend the great toe as far as possible while supinating and dorsiflexing the foot.
    The aim is to make the distance travelled by the FLH to the max.
    repeat again
    retest and I bet their symptoms are gone.
    Have done this many times and the U/S cannot find the click nor can the patient reproduce it.
    Been teaching this technique for 14 years or so.
  29. Asher

    Asher Well-Known Member

    Hi all

    I use this often for arch pain which I don't think is plantarfasciitis. It can work a treat.

  30. musmed

    musmed Active Member

    Dear Rebecca
    it is amazing how well the simple stuff works.
    Me thinks the majority forget that, 'The commonest things occur most commonly'....

    Short FHallLongus is the commonest cause of medial to heel foot pain I know of,
    as well as a major contributor to the 'Plantar Flexed First Ray'.

    May I be so bold as to say, There is no such thing as a plantar flexed first ray, just to say the first ray is heading into the plantar direction.

    The causes are:
    1. Joint(s)
    2. Muscle supporting those joints.

    Joints are:
    Navicular/Medial cunieform joints

    Flexor Hallicus Longus == tight or short
    Abductor Hallucis Longus == non functioning

    These failing groups are assured in most forefoot pain.

    I am willing to demonstrate this anywhere (provided you supply the airfare etc.)
    Come to Hobart This weekend to see for yourself!
    This is the best I can do currently.

    Happy thinking

    The weather here is beautiful (as it should be)
  31. drsarbes

    drsarbes Well-Known Member


    What exactly does THAT mean? If there is no such thing as a plantar flexed first ray then what, pray tell, am I accomplishing when I perform a dorsal wedge osteotomy at the first metabase?

    Some of your ideas are, to say the least, strange. Please let us know what pathology will cause an isolated "tightness" of the FHL. And the Abductor Hallucis LONGUS? Where is that exactly?

    I would suggst that if you do happen to find a tendon that is "shorter" or "tighter" then you think it should be it's normally a reactive condition; either the opposing mucscle (s) is/are weak (regardless of the reason) thus allowing it to contract
    unopposed ;


    All else being equal, in a normal situation, the physical distance between the origin to insertion of the muscle/tendon unit dictates the length (in a resting state.) PERIOD. If this distance is shortened then the muscle/tendon unit will assume a shorter resting state.

    Now, again, if you can describe a condition in which the FHL UNILATERALLY contracts and causes the Talo nav, Nav cuneiform and cun met joints to contract, then I'll stand corrected.

  32. musmed

    musmed Active Member

    Dear All

    There is no such thing as a plantar flexed ray...
    Simply put the ray is in the plantar direction but it is not flexed. It just follows what the mid foot joints tell it to do.
    Once you correct the mid foot joints by mobilisation/manipulation/or what ever, the first ray is no longer 'plantar flexed'.

    Your method of fixing the problem is a surgical one, so be it.
    I just set out to correct the cause not what I see as the problem.

    you wrote:
    All else being equal, in a normal situation, the physical distance between the origin to insertion of the muscle/tendon unit dictates the length (in a resting state.) PERIOD. If this distance is shortened then the muscle/tendon unit will assume a shorter resting state.

    This is not true. Muscle tone is affected by many things and gravity is one that plays a major role. That is what we treat people lying down. I do not know what is tone, I doubt anyone does.
    If you are unconscious you do not have tone. So tone must be within the conscious state.

    Joint position sense also sets the length of a muscle. If for example your elbow will only extend to 70 degrees instead of the normal 90 then the muscle will be set to 70 degrees. That is the role of a muscle ie to protect the joint nothing else.
    If manipulation of the elbow joint is possible and 90 degrees is returned immediately the muscle length will be 90 degrees.

    I made an error by putting longus after the abd. hallucis.
    The FHL is short in all patient with Plantar heel pain as far as I am aware. I test this muscle in all patients as well as the patients ability to activate the Adductor Hallucis.

    Tenderness when palpating the AHL is very common indeed. It is not the plantar fascia, you are just palpating through the plantar fascia.

    Regarding the surgery, where you wrote pray tell...
    You have changed the symptoms as far as I can see.

    May i ask have you ever looked at these joints as a possible cause of the problem?

    beautiful weather in Aus at present.
  33. drsarbes

    drsarbes Well-Known Member

    I'm not sure where to start with this.

    First, when you're unconscious you have no muscle tone?????
    Hmmmmmmmm. Well, that would mean that everyone who passes out would pass-on as well since our cardiac, intercostals and diaphram would have "no tone" - not to mention the anal sphincter......that can't be good.

    Of course, prior to that you stated that you didn't know what TONE was nor did anyone.
    For the record: Tone is the continuous and passive partial contraction of a muscle, i.e., a resting state.

    I still don't know what the AHL is.
    If you are referring to the AHB - well, many of us have very thorough surgical anatomy skills and I can tell you it would be difficult to confuse the AHB muscle belly for the plantar fascia, particularly that near the Os Calcis' medial plantar tubercle.

    Elbow ROM and tendon length.....I have no idea what you are trying to explain.

    BTW: No plantar flexed first ray? It does what the "mid foot joints" tell it to do. WOW!
    OK, manipulate a CMT patient and tell me if you can get the MID FOOT to tell the first ray to correct itself.

    I really don't mean to be argumentative, but I just can't read your posts and not respond.

    As far as surgery "changing the symptoms".....not sure what that means either. You must mean eliminating the symptoms.

    Last edited: Mar 24, 2009

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