Flexor hallucis longus tendon problems

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

The flexor hallucis longus (FHL) tendon is one of three structures that lie in the tarsal tunnel.

Located behind the medial malleolus (inside ankle bone), the FHL is the most posterolateral (to the rear and side). The FHL extends into the foot to insert onto the distal phalanx (the end bone) of the great toe. The FHL acts as a flexor of the great toe, elevates the arch, and assists with plantar flexion of the ankle (pointing the toes away from the body).

Patients with FHL tendon problems present with pain in the posteromedial aspect of the ankle (behind the inside ankle bone). The pain improves with rest and increases during activities requiring push-off and extended running.

Usually no tenderness on palpation is present due to the deep location of the tendon. Pain and weakness are noted with resistance to plantar flexion of the first MTP joint. Pain also may be present in the tarsal tunnel (the area just back of the inside ankle bone).

FHL tendinopathy (disorders of the tendon) is associated with repeated push-off maneuvers, such as those done by ballet performers or sprinters. Sometimes blunt trauma may also play a role.

Among the conditions that can mimic FHL problems are: Achilles tendinitis, tibialis posterior tendonitis, and tarsal tunnel syndrome.

Clinical findings include: swelling, pain, and tenderness posterior to the medial malleolus; pain along the tendon sheath that may occur with toe flexion (bending the toe down); and reduced ability to point the great toe up.

US imaging or MRI can help rule with diagnosis.

Treatment consists of immobilization, activity restrictions, and non-steroidal anti-inflammatory drugs (NSAIDs). Steroid injection is possible but caution must be exhibited because of the nerves and blood vessels that are located nearby.

Surgery is sometimes required.

The treatment of choice today is ultrasound-guided needle tenotomy with platelet-rich plasma. This is a procedure where a small needle is introduced using ultrasound guidance. The needle is used to "pepper" the damaged area with small holes to induce acute injury to stimulate inflammation. The platelet-rich plasma (PRP) is then introduced to help heal the tendon. The procedure is extremely effective and avoids the need for surgery.

For more great information on tendonitis, visit our new siteTendonitis and PRP

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