Functional hallux rigidus in high level athletes: Arthroscopic repair by flexor hallucis longus debridement

Authors

  • Brian Carpenter, DPM, FACFAS Professor, Department of Orthopaedics, University of North Texas Health Science Center, Fort Worth, Texas, USA
  • Michael Gentile, DPM, FACFAS Fellowship Director, Portland Foot and Ankle Reconstructive Fellowship; Private Practice: Portland Foot and Ankle Institute, Portland, Oregon, USA
  • Jacob Russell Hagenbucher, DPM, AACFAS Fellow, Portland Foot and Ankle Reconstructive Fellowship, Portland, Oregon, USA

DOI:

https://doi.org/10.55067/jifaf.v1i1.1

Keywords:

athletes, hallux limitus, flexor hallucis longus, FHL, first metatarsal phalangeal joint, MTPJ, retrotalar pulley, zone 1, impingement

Abstract

This study aimed at the surgical technique and long-term clinical outcome of releasing the retrotalar pulley and surgical debulking of the flexor hallucis longus muscle belly to restore motion to the first metatarsophalangeal joint. Hallux limitus is defined as a limitation of motion at the first metatarsophalangeal joint.  Numerous etiologies have been described, but most are concentrated within the first ray, especially the first metatarsophalangeal joint.  We present a series of patients with hallux limitus caused by impingement of the flexor hallucis longus tendon within the retrotalar pulley due to a hypertrophic and/or low-lying muscle belly.  Arthroscopic surgical debridement of the retrotalar pulley and surgical debulking of the flexor hallucis longus muscle belly in the posterior ankle compartment resolved all symptoms at the 1st metatarsophalangeal joint and restored normal motion of the first metatarsophalangeal joint allowing all high level athletes to return to their respective sports with no limitations.

References

Payne C, Chuter V, Miller K. Sensitivity and specificity of the functional hallux limitus test to predict foot function. J Am Podiatr Med Assoc. 2002 May;92(5):269-71. doi: 10.7547/87507315-92-5-269. PMID: 12015407.

Ahmad J, Jones K, Raikin SM. Treatment of Chronic Achilles Tendon Ruptures With Large Defects. Foot Ankle Spec. 2016 Oct;9(5):400-8. doi: 10.1177/1938640016640895. Epub 2016 Mar 21. PMID: 27000133.

Martinez-Salazar EL, Vicentini JRT, Johnson AH, Torriani M. Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings. Skeletal Radiol. 2018 May;47(5):747-750. doi: 10.1007/s00256-017-2853-9. Epub 2017 Dec 28. PMID: 29285554.

Vallotton J, Echeverri S, Dobbelaere-Nicolas V. Functional hallux limitus or rigidus caused by a tenodesis effect at the retrotalar pulley: description of the functional stretch test and the simple hoover cord maneuver that releases this tenodesis. J Am Podiatr Med Assoc. 2010 May-Jun;100(3):220-9. doi: 10.7547/1000220. PMID: 20479455.

Rodriguez D, Devos Bevernage B, Maldague P, Deleu PA, Leemrijse T. Tarsal tunnel syndrome and flexor hallucis longus tendon hypertrophy. Orthop Traumatol Surg Res. 2010 Nov;96(7):829-31. doi: 10.1016/j.otsr.2010.03.026. Epub 2010 Sep 18. PMID: 20851075.

Tzioupis C, Oliveto A, Grabherr S, Vallotton J, Riederer BM. Identification of the retrotalar pulley of the Flexor Hallucis Longus tendon. J Anat. 2019 Oct;235(4):757-764. doi: 10.1111/joa.13046. Epub 2019 Jul 5. PMID: 31274195; PMCID: PMC6742900.

Smyth NA, Zwiers R, Wiegerinck JI, Hannon CP, Murawski CD, van Dijk CN, Kennedy JG. Posterior hindfoot arthroscopy: a review. Am J Sports Med. 2014 Jan;42(1):225-34. doi: 10.1177/0363546513491213. Epub 2013 Jul 18. PMID: 23868522.

Lui TH, Chan KB, Chan LK. Zone 2 flexor hallucis longus tendoscopy: a cadaveric study. Foot Ankle Int. 2009 May;30(5):447-51. doi: 10.3113/FAI-2009-0447. PMID: 19439147.

Lui TH. Flexor hallucis longus tendoscopy: a technical note. Knee Surg Sports Traumatol Arthrosc. 2009 Jan;17(1):107-10. doi: 10.1007/s00167-008-0623-x. Epub 2008 Sep 13. PMID: 18791699.

van Dijk CN, Scholten PE, Krips R. A 2-portal endoscopic approach for diagnosis and treatment of posterior ankle pathology. Arthroscopy. 2000 Nov;16(8):871-6. doi: 10.1053/jars.2000.19430. PMID: 11078550.

Kudaş S, Dönmez G, Işık Ç, Çelebi M, Çay N, Bozkurt M. Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes. Acta Orthop Traumatol Turc. 2016 Dec;50(6):649-654. doi: 10.1016/j.aott.2016.03.008. Epub 2016 Dec 3. PMID: 27919560; PMCID: PMC6197591.

Hamilton WG, Geppert MJ, Thompson FM. Pain in the posterior aspect of the ankle in dancers. Differential diagnosis and operative treatment. J Bone Joint Surg Am. 1996 Oct;78(10):1491-500. doi: 10.2106/00004623-199610000-00006. PMID: 8876576.

Hedrick MR, McBryde AM. Posterior ankle impingement. Foot Ankle Int. 1994 Jan;15(1):2-8. doi: 10.1177/107110079401500102. PMID: 7981792.

Oksanen MM, Haapasalo HH, Elo PP, Laine HJ. Hypertrophy of the flexor hallucis longus muscle after tendon transfer in patients with chronic Achilles tendon rupture. Foot Ankle Surg. 2014 Dec;20(4):253-7. doi: 10.1016/j.fas.2014.06.003. Epub 2014 Jul 2. PMID: 25457661.

Yamamoto JB, Yamamoto BE, Yamamoto PP, Yamamoto LG. Epidemiology of college athlete sizes, 1950s to current. Res Sports Med. 2008;16(2):111-27. doi: 10.1080/15438620802103320. PMID: 18569945.

Sands WA, Slater C, McNeal JR, Murray SR, Stone MH. Historical trends in the size of US Olympic female artistic gymnasts. Int J Sports Physiol Perform. 2012 Dec;7(4):350-6. doi: 10.1123/ijspp.7.4.350. Epub 2012 May 29. PMID: 22645197.

Cholewa J, Trexler E, Lima-Soares F, de Araújo Pessôa K, Sousa-Silva R, Santos AM, Zhi X, Nicastro H, Cabido CET, de Freitas MC, Rossi F, Zanchi NE. Effects of dietary sports supplements on metabolite accumulation, vasodilation and cellular swelling in relation to muscle hypertrophy: A focus on "secondary" physiological determinants. Nutrition. 2019 Apr;60:241-251. doi: 10.1016/j.nut.2018.10.011. Epub 2018 Oct 10. PMID: 30682546.

VanDijk C. Posterior ankle impingement. In: VanDijk C, ed. Ankle arthroscopy. Berlin, Heidelberg: Springer, 2014:231-258.

Petersen W, Pufe T, Zantop T, Paulsen F. Blood supply of the flexor hallucis longus tendon with regard to dancer's tendinitis: injection and immunohistochemical studies of cadaver tendons. Foot Ankle Int. 2003 Aug;24(8):591-6. doi: 10.1177/107110070302400804. PMID: 12956563.

Adams S, Parekh S. Tendon Disorders. India, Jaypee Brothers, Medical Publishers Pvt. Limited, 2012:292-331.

Tomassen E. Disease and injuries of ballet dancers 1982; Aarhus, Denmark. Universitetsforlaget I Aarhus.

Lo LD, Schweitzer ME, Fan JK, Wapner KL, Hecht PJ. MR imaging findings of entrapment of the flexor hallucis longus tendon. AJR Am J Roentgenol. 2001 May;176(5):1145-8. doi: 10.2214/ajr.176.5.1761145. PMID: 11312169.

Paús V, Graieb A, Torrengo F, Villalba F. Diagnosis of chronic exertional compartment syndrome by post-exercise MRI. Orthop J Sports Med. 2017 Jan 31;5(1 Suppl):2325967117S00001. doi: 10.1177/2325967117S00001. PMCID: PMC5318822.

Holcomb TM, Temple EW, Barp EA, Smith HL. Surgical correction of checkrein deformity after malunited distal tibia fracture: a case report. J Foot Ankle Surg. 2014 Sep-Oct;53(5):631-4. doi: 10.1053/j.jfas.2014.04.028. Epub 2014 Jun 15. PMID: 24942372.

Rosenberg GA, Sferra JJ. Checkrein deformity--an unusual complication associated with a closed Salter-Harris Type II ankle fracture: a case report. Foot Ankle Int. 1999 Sep;20(9):591-4. doi: 10.1177/107110079902000910. PMID: 10509688.

Yuen CP, Lui TH. Adhesion of flexor hallucis longus at the site of a tibial-shaft fracture--a cause of a checkrein deformity. Foot Ankle Surg. 2015 Mar;21(1):e23-6. doi: 10.1016/j.fas.2014.09.011. Epub 2014 Oct 22. PMID: 25682418.

de Leeuw PA, van Sterkenburg MN, van Dijk CN. Arthroscopy and endoscopy of the ankle and hindfoot. Sports Med Arthrosc Rev. 2009 Sep;17(3):175-84. doi: 10.1097/JSA.0b013e3181a5ce78. PMID: 19680114.

Ogut T, Ayhan E, Irgit K, Sarikaya AI. Endoscopic treatment of posterior ankle pain. Knee Surg Sports Traumatol Arthrosc. 2011 Aug;19(8):1355-61. doi: 10.1007/s00167-011-1428-x. Epub 2011 Feb 11. PMID: 21311860.

Heier KA, Hanson TW. Posterior Ankle Impingement Syndrome. Operative Techniques in Sports Medicine. 2017 25(2), 75-81. doi: 10.1053/j.otsm.2017.03.005

Ribbans WJ, Ribbans HA, Cruickshank JA, Wood EV. The management of posterior ankle impingement syndrome in sport: a review. Foot Ankle Surg. 2015 Mar;21(1):1-10. doi: 10.1016/j.fas.2014.08.006. Epub 2014 Sep 22. PMID: 25682399.

Feng SM, Sun QQ, Wang AG, Fan JQ. Flexor Hallucis Longus Tendon Impingement Syndrome: All-inside Arthroscopic Treatment and Long-term Follow-up. J Foot Ankle Surg. 2020 Nov-Dec;59(6):1197-1200. doi: 10.1053/j.jfas.2020.05.014. Epub 2020 Jun 9. PMID: 32828632.

Downloads

Published

2021-12-28

How to Cite

1.
Carpenter B, Gentile M, Russell Hagenbucher J. Functional hallux rigidus in high level athletes: Arthroscopic repair by flexor hallucis longus debridement. J Int Foot Ankle [Internet]. 2021 Dec. 28 [cited 2022 Aug. 14];1(1). Available from: https://internationalfootankle.org/journal/index.php/JIFAF/article/view/1