Questions about ? FHL rupture.

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Hi All,

I've recently had a patient (female, mid fourties, slim, no other things of note) referred for plantar fasciitis. I suspect it may actually be a FHL rupture. No first step pain, pain after increased duration of standing/walking.. She had a 1+ year history of "heel-pain" and pain in the arch, had 2x steroid injections in the heel and then felt a snapping sensation in the middle of the arch of the R foot. Had considerable pain ever since.

Pt displays reduced power plantar flexion of the R/hallux, pain on active plantar flexion, resisting dorsi-flexion, pain on palpation of the highest point of MLA. No pain on palp of insertion of plantar fascia, no pain along the course of the FHL distal to the painful site. During the gait cycle the pain seems to be at it's worst just after heel lift, and I believe the patient is compensating by using a low gear gait pattern through this foot and toeing off over the 3-4th met head area.

We have tried a couple of insoles (Modified formthotics (added heel wedge and arch filler) and then poly prop custom made), foot wear and low dye strapping with minimal effect on pain. I currently have her in a sample from eurothoics I had lying around the office.. it is a fairly rigid plate (not entirely sure of the material but looks like a hard plastic interwoven fibre, had a walk around in one my size and it's got a bit of spring in it and seems like it reduces hallux dorsiflexion) with an extension out under the first MPJ. Using it as a temporary pain reducing measure, would like to take this out ASAP. Straight away the patient said the pain was reduced so I'm awaiting the next appointment to RV her and see if this insole has been successful.

Referred back to the referring ortho with a detailed memo asking for US or MRI and he very kindly sent the pt for x-ray :bang: re-rereferred back to him for US or MRI and went round to his clinic and spoke to him very politely.. US scan booked soon. Will give results when I get them..

I was just wondering what treatment options would be for the patient.. I'm guessing if there is a partial tear the most likely course of action would be surgical tendon repair?? What are the chances that conservative methods would be successful? This obviously assumes my Dx is correct also. If it was a full rupture would the patient still be in pain?

Also, as an aside, I just wanted to get a consensus on how many people are using, or have access to an ultrasound imaging machine in their day to day practice? I have played around with an US imaging machine and after about 4 hours of seeing grey fuzz I could start to pick out obvious structures.. I feel that with appropriate training and access to US I could have done the US imaging there and then, saving several weeks of inappropriate investigations. Any one know how much people are using this and if there are any recognised courses for podiatric ultrasound?

Questions, questions, questions....

Yours thankingly,

Sam

 

If there is a partial tear, a course of immobilization 6- 8 weeks is often very helpful. Do they have increased pain on plantarflexion of the flexor tendon against resistance? Is there a palpable gap?

An MRI will provide a clearer image but for tendon tears, US gives a dynamic study and is preferred by our group for tendon problems. The cheaper machines are hard to use. It is like looking through a dirty window. We have just started using diagnostic US in our office and tendons are fairly easy to see and follow along their course.

 

Sam:

Flexor hallucis longus (FHL) tendon complete ruptures are relatively easy to diagnose since the FHL is the only muscle that can exert a plantarflexion moment at the hallux interphalangeal joint (IPJ). Therefore, if the patient can't plantarflex their hallux IPJ (i.e. stabilize their hallux proximal phalanx with your hand and then have the patient attempt to plantarflex the distal phalanx relative to the proximal phalanx), then there is not a complete rupture of the FHL.

Rather than a FHL tendon rupture, my guess is the patient has had a partial tear of the medial fibers of the central component of the plantar aponeurosis (i.e. plantar fascia) which is a very common injury. To diagnose a partial tear of the medial fibers of the central component of the plantar aponeurosis, with the patient supine, place a strong dorsiflexion force on the hallux proximal phalanx and first metatarsal head simultaneously to load the plantar fascia against the resultant Achilles tendon tensile force. Then, with the opposite hand, run your thumb forcefully along the course of the medial fibers of the central component from the sesamoids to the medial calcanel tubercle. A partial tear will present as a defect on palpation and will have the maximum tenderness at this defect and the plantar fascia may show less bowstringing/more compliance when comparing the same test to the contralateral foot. No ultrasound or MRI scan is necessary to make these diagnoses, but, unfortunately, not many podiatrists or clinicians know how to examine a foot well enough anymore due to their continued and increasing reliance on these tests. I guess I'm becoming a dinosaur since I prefer manual examination skills which take seconds to perform with no extra cost to the patient compared to other tests which takes days or weeks to perform and may cost the patient hundreds if not thousands of dollars.

By the way, a spontaneous rupture of the FHL tendon is an uncommon injury.

Hope this helps.

 

Thanks for the reply Mr/Dr...??

No palpable gap, and there is pain on the flexor tendon against resistance..

Thanks for the info on US stuff..

Regards,

Sam

 

Kevin, thank you for the detailed reply.. :drinks

The patient is able to plantarflex at the IPJ, so it is not a complete (if any at all) rupture. The thing that was pointing me towards FHL rupture was the decreased strength that is displayed at the 1st MPJ. Also my plantar fascia rest strapping/taping had no effect on pain at all.. am I wrong to assume that this strapping would have a positive effect on symptoms in a rupture of the plantar fascia?

The other thing that I was thinking is that during gait I find plantar fascia patients report that their pain tends to be more evident in the foot during forefoot loading, when the foot is pronating and the plantar fascia is being loaded, rather than heel lift/toe off where it is helping to resupinate the foot, which is when my patient gets the most pain.

I was aware that FHL rupture was unlikely, and to be honest, I was treating the patient as a Plantar Fasciitis case for her first 2 visits with me. It was only when nothing was working that i started to reassess the original diagnosis she was given.

Sorry to question so much..

Yours questionably,

Sam

 

When in doubt the most obvious cause is the most likely. FHL pathology is rare in comparison to medial fascial slip tears.

You are dancing in the dark unless your palpation and physical examination skills are fine tuned (as discussed by Dr Kirby), or you get some appropriate imaging. US should easily determine this pathoogy at low cost to the patient, so MR is rarely indicated in conservative management.

It is never the wrong thing just to plonk a CAM walker on these people until you find out for sure. IMHO almost every musculoskeletal pathology of the foot and ankle feels significantly better in one of these within 24-48hrs. Almost never the wrong thing to do, and I keep a few of these on hand in the clinic to dish out whenever a traumatic injury is at hand.

LL