Isolated rupture of the flexor hallucis tendon A
case
longus
report
KEITH W. G.
HOLT, MBBS, FRACS, AND MERVYN J. CROSS,* MBBS, FRACS
From the Clinical Research Department, North
Sydney Orthopaedic and Sports Medicine
Centre, North Sydney, New South Wales, Australia Partial and complete rupture of the flexor hallucis longus tendon has been well described in ballet dancers,2, 3, with the lesion developing at the proximal end of the tendon sheath behind the talus. Similarly, flexor hallucis tenosynovitis in young active males’ and in long distance athletes,4 has been well described. We are presenting a case where, following tenosynovitis in the foot of a long distance athlete, complete rupture of the flexor hallucis longus tendon occurred in the midfoot. It was unrelated to injury, abnormal anatomy, steroid injections, or identifiable systemic abnormalities. To our knowledge, such a case has not been previously described.
always run predominantly on the medial aspect of her forefoot ; therefore, in the right foot this pattern was increased by her overpronation. She gave up competitive marathons, but continued to train from 120 to 150 kilometers per week. She consequently varied this so that up to 10% of that distance was on hilly or rough ground. This was in preparation for her cross country and orienteering pursuits. Two months prior to presentation she gradually developed increasing arch pain in the right foot. Ten days prior to presentation she was running over hilly ground when she felt a painful giving way in her foot, associated with weakness of toe flexion. After exercise she had swelling in the sole of her foot, which she treated with ice and elevation. She continued to train, however, and a week later had a second episode during a run, where she lost complete flexor power of her great toe and, incidentally, also lost some of her arch pain. We saw her 3 days later and made a preop-
CASE REPORT A 42-year-old female athlete presented with pain that was associated with loss of function of the flexor hallucis longus tendon in the arch of the right foot. The patient had normal foot anatomy with normal arch development, is of normal to light build, had no ligamentous laxity, was neurologically normal, and had had no steroid or other injections in or about the foot. Examination confirmed total rupture of the tendon and the area of pain localization suggested that the lesion was in the midfoot area. The patient, originally a sprinter, took up long distance running at the age of 32, and over the next 4 years improved so as to become ranked in the top 10 female athletes in the world over the marathon distance. Following this, however, she developed mild anterolateral thigh pain, which proved relatively resistant to treatment. Because of this, a change in running style was necessary, and it was noted that she gradually began running with the right leg slightly externally rotated and the right foot compensatorily pronated. She had
erative
diagnosis of
ture in the midfoot
an
isolated flexor hallucis tendon rup-
region.
This rupture was confirmed at surgery (Fig. 1) and was specifically located at the level of the distal talus where the
tendon emerges from its proximal fibrous sheath. The tendon ends were able to be repaired by direct suture without
appreciable loss of length (Fig. 2). Postoperative
treatment
consisted of cast immobilization for 8 weeks and then gradual mobilization with programed physiotherapy, swimming, and bicycle riding. Approximately 8 weeks after removal of the cast, she began jogging again. Toe function was good, painless, and showed a 70% range of movement at the metatarsophalangeal joint in comparison to the other side, with equal restriction at both extremes. Interphalangeal joint function showed a range of 0° to 25°, again representing about 70% of the range of the opposite toe. She began early jogging exercises at this time and, over the 2 months since that time, went on to increase her jogging time and distance, nearly accomplishing preoperative levels of training.
*
Address correspondence and reprint requests to: Mervyn J. Cross, MBBS, FRACS, North Sydney Orthopaedic and Sports Medicine Centre, 286 Pacific Highway, Crows Nest, Australia 2065.
645
646
DISCUSSION
Figure 1. Ruptured tendon ends of the flexor hallucis longus in the midfoot.
Isolated rupture of the flexor hallucis longus tendon in the sole of the foot has not been previously reported. In our patient it was thought that the tendon degeneration and subsequent rupture occurred through overuse. It was felt that the contributing factor to this isolated, unilateral rupture in the right foot was the increased foot pronation caused by the adoption of an externally rotated posture of the leg, which gave some relief to an injury located more proximally in the limb. This, associated with an alteration of training program to include more uphill work superimposed on already high weekly training distances, in an athlete who ran predominantly on her medial forefoot, could well suggest an overuse of the long flexor tendon. No other local or systemic cause could be identified that could be implicated in the development of this condition. Despite some controversy in the need for a functioning flexor hallucis longus tendon in pushoff,’ and despite good results in young athletes who have had no repair of isolated flexor hallucis longus tendon lacerations,’ it was felt that in this unusual case, where rupture had seemingly occurred in a top level athlete, exploration to define the abnormality was justified. Subsequent postoperative progress has borne out this decision; therefore, we would recommend early
primary repair of all similar lesions. REFERENCES 1. Frenette JP, Jackson DW: Lacerations of the flexor hallucis longus in the young athlete. J Bone Joint Surg 59A: 673-676, 1977 2. Garth WP Jr: Flexor hallucis tendinitis in a ballet dancer. J Bone Joint Surg
63A: 1489, 1981 3. Jahss MH: The foot and ankle in classical and modern dance, in The Foot. Ch 59. Philadelphia, WB Saunders Co, 1982 4. Jahss MH: Sports injuries to the foot and ankle, in The Foot. Ch 57. Philadelphia, WB Saunders Co, 1982 5. Jahss MH: Sports injuries to the foot and ankle, in The Foot. Ch 29. Philadelphia, WB Saunders Co, 1982 6. MacConaill MA, Benjamin JV: Muscles and Movements. A Basis for Human Kinesiology. Baltimore, Williams & Wilkins, 1969 7. Sammarco GJ, Miller EH: Partial rupture of the flexor hallucis tendon in classical ballet dancers. J Bone Joint Surg 61A: 149-150, 1979
Figure 2. Apposition of the flexor hallucis longus tendon.
case
longus
report
KEITH W. G.
HOLT, MBBS, FRACS, AND MERVYN J. CROSS,* MBBS, FRACS
From the Clinical Research Department, North
Sydney Orthopaedic and Sports Medicine
Centre, North Sydney, New South Wales, Australia Partial and complete rupture of the flexor hallucis longus tendon has been well described in ballet dancers,2, 3, with the lesion developing at the proximal end of the tendon sheath behind the talus. Similarly, flexor hallucis tenosynovitis in young active males’ and in long distance athletes,4 has been well described. We are presenting a case where, following tenosynovitis in the foot of a long distance athlete, complete rupture of the flexor hallucis longus tendon occurred in the midfoot. It was unrelated to injury, abnormal anatomy, steroid injections, or identifiable systemic abnormalities. To our knowledge, such a case has not been previously described.
always run predominantly on the medial aspect of her forefoot ; therefore, in the right foot this pattern was increased by her overpronation. She gave up competitive marathons, but continued to train from 120 to 150 kilometers per week. She consequently varied this so that up to 10% of that distance was on hilly or rough ground. This was in preparation for her cross country and orienteering pursuits. Two months prior to presentation she gradually developed increasing arch pain in the right foot. Ten days prior to presentation she was running over hilly ground when she felt a painful giving way in her foot, associated with weakness of toe flexion. After exercise she had swelling in the sole of her foot, which she treated with ice and elevation. She continued to train, however, and a week later had a second episode during a run, where she lost complete flexor power of her great toe and, incidentally, also lost some of her arch pain. We saw her 3 days later and made a preop-
CASE REPORT A 42-year-old female athlete presented with pain that was associated with loss of function of the flexor hallucis longus tendon in the arch of the right foot. The patient had normal foot anatomy with normal arch development, is of normal to light build, had no ligamentous laxity, was neurologically normal, and had had no steroid or other injections in or about the foot. Examination confirmed total rupture of the tendon and the area of pain localization suggested that the lesion was in the midfoot area. The patient, originally a sprinter, took up long distance running at the age of 32, and over the next 4 years improved so as to become ranked in the top 10 female athletes in the world over the marathon distance. Following this, however, she developed mild anterolateral thigh pain, which proved relatively resistant to treatment. Because of this, a change in running style was necessary, and it was noted that she gradually began running with the right leg slightly externally rotated and the right foot compensatorily pronated. She had
erative
diagnosis of
ture in the midfoot
an
isolated flexor hallucis tendon rup-
region.
This rupture was confirmed at surgery (Fig. 1) and was specifically located at the level of the distal talus where the
tendon emerges from its proximal fibrous sheath. The tendon ends were able to be repaired by direct suture without
appreciable loss of length (Fig. 2). Postoperative
treatment
consisted of cast immobilization for 8 weeks and then gradual mobilization with programed physiotherapy, swimming, and bicycle riding. Approximately 8 weeks after removal of the cast, she began jogging again. Toe function was good, painless, and showed a 70% range of movement at the metatarsophalangeal joint in comparison to the other side, with equal restriction at both extremes. Interphalangeal joint function showed a range of 0° to 25°, again representing about 70% of the range of the opposite toe. She began early jogging exercises at this time and, over the 2 months since that time, went on to increase her jogging time and distance, nearly accomplishing preoperative levels of training.
*
Address correspondence and reprint requests to: Mervyn J. Cross, MBBS, FRACS, North Sydney Orthopaedic and Sports Medicine Centre, 286 Pacific Highway, Crows Nest, Australia 2065.
645
646
DISCUSSION
Figure 1. Ruptured tendon ends of the flexor hallucis longus in the midfoot.
Isolated rupture of the flexor hallucis longus tendon in the sole of the foot has not been previously reported. In our patient it was thought that the tendon degeneration and subsequent rupture occurred through overuse. It was felt that the contributing factor to this isolated, unilateral rupture in the right foot was the increased foot pronation caused by the adoption of an externally rotated posture of the leg, which gave some relief to an injury located more proximally in the limb. This, associated with an alteration of training program to include more uphill work superimposed on already high weekly training distances, in an athlete who ran predominantly on her medial forefoot, could well suggest an overuse of the long flexor tendon. No other local or systemic cause could be identified that could be implicated in the development of this condition. Despite some controversy in the need for a functioning flexor hallucis longus tendon in pushoff,’ and despite good results in young athletes who have had no repair of isolated flexor hallucis longus tendon lacerations,’ it was felt that in this unusual case, where rupture had seemingly occurred in a top level athlete, exploration to define the abnormality was justified. Subsequent postoperative progress has borne out this decision; therefore, we would recommend early
primary repair of all similar lesions. REFERENCES 1. Frenette JP, Jackson DW: Lacerations of the flexor hallucis longus in the young athlete. J Bone Joint Surg 59A: 673-676, 1977 2. Garth WP Jr: Flexor hallucis tendinitis in a ballet dancer. J Bone Joint Surg
63A: 1489, 1981 3. Jahss MH: The foot and ankle in classical and modern dance, in The Foot. Ch 59. Philadelphia, WB Saunders Co, 1982 4. Jahss MH: Sports injuries to the foot and ankle, in The Foot. Ch 57. Philadelphia, WB Saunders Co, 1982 5. Jahss MH: Sports injuries to the foot and ankle, in The Foot. Ch 29. Philadelphia, WB Saunders Co, 1982 6. MacConaill MA, Benjamin JV: Muscles and Movements. A Basis for Human Kinesiology. Baltimore, Williams & Wilkins, 1969 7. Sammarco GJ, Miller EH: Partial rupture of the flexor hallucis tendon in classical ballet dancers. J Bone Joint Surg 61A: 149-150, 1979
Figure 2. Apposition of the flexor hallucis longus tendon.
