0198-0211/90/1005-0288$02.00/0 FOOT8 ANKLE Copyright 0 1990 by t h e American Orthopaedic Foot and Ankle Society, Inc.
Rupture of the Flexor Hallucis Longus Tendon: Case Report Roar B. Rasmussen,* M.D. and Erik P. Thyssen, M.D. HolbEk Hospital, Holbaek, Denmark
only minimum active flexion of the interphalangealjoint but no limitations in passive movement. He felt no inconvenience and has returned to his work as a carpenter without problems.
ABSTRACT A case of acute rupture of the flexor hallucis longus tendon is described. This occurrence is rare and has only been reported in connection with other lesions. A gliding tendon is apparently not essential to obtain good functional results in such a case of rupture or laceration.
DISCUSSION
Lesion of the flexor hallucis longus tendon is most frequently seen in association with open injuries and often associated with other injuries of the foot.',' If the rupture of the flexor hallucis longus tendon is the only injury, the diagnosis is not difficult, but the rupture can be overlooked in the presence of other injuries. Apart from the case reported by Krackow3we have not seen reports on complete rupture of the flexor hallucis longus tendon. Two cases of partial rupture of the flexor hallucis longus tendon in ballet dancers have been r e p ~ r t e dThe . ~ central fibers in the tendon were ruptured causing a thickening of the tendon located a little below the level of the ankle. The reason for the tendon rupture in our patient was apparently forceful extension against a contracted flexor hallucis longus muscle. We found at surgery no sign of underlying disease of the tendon and the patient had not observed any disability from the foot before the accident. The tendon rupture in both Krackow's and our case was localized distally, l/2 and l h 3 / 4 cm from its insertion, respectively. This perhaps reveals a tendency for the tendon to rupture distally in cases of forceful extension while long-lasting strain may result in more proximaly located lesions. However, if a suspected rupture is not found distally the tendon may need to be examined more thoroughly. The majority of surgeons will presumably prefer primary suture of a ruptured flexor hallucis longus t e n d ~ n . ~ In a report of 10 cases of open lacerations of the flexor hallucis longus tendon six patients had primary suture performed.' Four of the six had no appreciable active motion of the interphalangealjoint, but no patients had any serious inconveniences. In four patients the flexor hallucis longus tendon was not repaired, and one was later operated on because of hyperextension of the metatarsophalangealjoint.
INTRODUCTION
Tendon ruptures in the foot are rare apart from rupture of the achilles tendon. Acute rupture of the flexor hallucis longus tendon has been reported in only one patient following an injury involving other parts of the foot3 Isolated rupture of the flexor hallucis longus tendon following minor injuries has to our knowledge not been reported. We present a case of rupture of the flexor hallucis longus tendon following a minor injury, and describe the lesion, diagnosis and treatment. CASE REPORT
A 34-year-old male twisted his right foot without falling while lifting a minor object. He felt a crack in his right forefoot. On examination the right first toe was found without wounds or tenderness, but was held in extension. Test of active motion of the toe revealed good flexion power in the metatarsophalangealjoint but no active flexion in the interphalangeal joint. X-ray of the foot showed no fracture. Because of the clinical suspicion of rupture of the flexor hallucis longus tendon the patient was operated on using a medial-longitudinalincision. The tendon rupture was found cm proximal to its insertion. The proximal end of the tendon was pulled down and the ends of the tendon were sutured. Immobilization was secured in a below-the-kneeplaster cast with the great toe in slight flexion for 6 weeks. On examination 13 months postoperativelythere was From the Department of Orthopaedic Surgery, HolbEk Hospital, DK-4300 HolbEk, Denmark. To whom requests for reprints and correspondence should be addressed at: lmmerkier 30 D, 2650 Hvidovre, Denmark.
288
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Foot & Ankle/Vol. 10, No. 5IApril 1990
RUPTURE OF THE FHL
In a later report or 13 cases of laceration of the flexor hallucis longus tendon, 10 had primary suture performed, two delayed suture, and one was not sutured.’ Nine of the 12 with repair had active interphalangeal joint flexion. The remaining three had no flexion, but had no functional problems. In the two above mentioned studies, none of the seven patients who had repair performed, but was without function of the tendon, had any major functional disabilities. Of all five patients without repair one had a major and one a minor problem. Floyd et al. (1983) found no limitation of passive extension of the great toe due to scarring. Our patient had free passive movement. The flexor hallucis longus tendon does not seem to be essential in achieving good functional results in case of rupture or laceration. The studies are small and not conclusive in favor of either surgical or conservative
289
treatment, but an attempt to repair the tendon in cases of laceration or rupture seems justified. In our patient, repair did not restore function of the great toe but the patient was without complaints.
REFERENCES 1. Floyd, D.W., Heckman, J.D., and Rockwood, Jr., C.A.: Tendon lacerations in the foot. Foot Ankle, 48-14, 1983. 2. Frenette, J.P., and Jackson, D.W.: Lacerations of the flexor hallucis longus in the young athlete. J. Bone Joint Surg., 59A673-676,1977. 3. Krackow, K.A.: Acute traumatic rupture of a flexor hallucis longus tendon. Clin. Orthop. Res., 150261-262, 1980. 4. Sarnarco, G.J., and Miller, E.H.: Partial rupture of the flexor hallucis longus tendon in classical ballet dancers. J. Bone Joint Surg., 61A149-150, 1979. 5. Yancey, H.A.: Laceration of the plantar aspect of the foot. Clin. Orthop. Res., 12246-52,1977.
Downloaded from fai.sagepub.com at UNIV TORONTO on June 5, 2016
Rupture of the Flexor Hallucis Longus Tendon: Case Report Roar B. Rasmussen,* M.D. and Erik P. Thyssen, M.D. HolbEk Hospital, Holbaek, Denmark
only minimum active flexion of the interphalangealjoint but no limitations in passive movement. He felt no inconvenience and has returned to his work as a carpenter without problems.
ABSTRACT A case of acute rupture of the flexor hallucis longus tendon is described. This occurrence is rare and has only been reported in connection with other lesions. A gliding tendon is apparently not essential to obtain good functional results in such a case of rupture or laceration.
DISCUSSION
Lesion of the flexor hallucis longus tendon is most frequently seen in association with open injuries and often associated with other injuries of the foot.',' If the rupture of the flexor hallucis longus tendon is the only injury, the diagnosis is not difficult, but the rupture can be overlooked in the presence of other injuries. Apart from the case reported by Krackow3we have not seen reports on complete rupture of the flexor hallucis longus tendon. Two cases of partial rupture of the flexor hallucis longus tendon in ballet dancers have been r e p ~ r t e dThe . ~ central fibers in the tendon were ruptured causing a thickening of the tendon located a little below the level of the ankle. The reason for the tendon rupture in our patient was apparently forceful extension against a contracted flexor hallucis longus muscle. We found at surgery no sign of underlying disease of the tendon and the patient had not observed any disability from the foot before the accident. The tendon rupture in both Krackow's and our case was localized distally, l/2 and l h 3 / 4 cm from its insertion, respectively. This perhaps reveals a tendency for the tendon to rupture distally in cases of forceful extension while long-lasting strain may result in more proximaly located lesions. However, if a suspected rupture is not found distally the tendon may need to be examined more thoroughly. The majority of surgeons will presumably prefer primary suture of a ruptured flexor hallucis longus t e n d ~ n . ~ In a report of 10 cases of open lacerations of the flexor hallucis longus tendon six patients had primary suture performed.' Four of the six had no appreciable active motion of the interphalangealjoint, but no patients had any serious inconveniences. In four patients the flexor hallucis longus tendon was not repaired, and one was later operated on because of hyperextension of the metatarsophalangealjoint.
INTRODUCTION
Tendon ruptures in the foot are rare apart from rupture of the achilles tendon. Acute rupture of the flexor hallucis longus tendon has been reported in only one patient following an injury involving other parts of the foot3 Isolated rupture of the flexor hallucis longus tendon following minor injuries has to our knowledge not been reported. We present a case of rupture of the flexor hallucis longus tendon following a minor injury, and describe the lesion, diagnosis and treatment. CASE REPORT
A 34-year-old male twisted his right foot without falling while lifting a minor object. He felt a crack in his right forefoot. On examination the right first toe was found without wounds or tenderness, but was held in extension. Test of active motion of the toe revealed good flexion power in the metatarsophalangealjoint but no active flexion in the interphalangeal joint. X-ray of the foot showed no fracture. Because of the clinical suspicion of rupture of the flexor hallucis longus tendon the patient was operated on using a medial-longitudinalincision. The tendon rupture was found cm proximal to its insertion. The proximal end of the tendon was pulled down and the ends of the tendon were sutured. Immobilization was secured in a below-the-kneeplaster cast with the great toe in slight flexion for 6 weeks. On examination 13 months postoperativelythere was From the Department of Orthopaedic Surgery, HolbEk Hospital, DK-4300 HolbEk, Denmark. To whom requests for reprints and correspondence should be addressed at: lmmerkier 30 D, 2650 Hvidovre, Denmark.
288
Downloaded from fai.sagepub.com at UNIV TORONTO on June 5, 2016
Foot & Ankle/Vol. 10, No. 5IApril 1990
RUPTURE OF THE FHL
In a later report or 13 cases of laceration of the flexor hallucis longus tendon, 10 had primary suture performed, two delayed suture, and one was not sutured.’ Nine of the 12 with repair had active interphalangeal joint flexion. The remaining three had no flexion, but had no functional problems. In the two above mentioned studies, none of the seven patients who had repair performed, but was without function of the tendon, had any major functional disabilities. Of all five patients without repair one had a major and one a minor problem. Floyd et al. (1983) found no limitation of passive extension of the great toe due to scarring. Our patient had free passive movement. The flexor hallucis longus tendon does not seem to be essential in achieving good functional results in case of rupture or laceration. The studies are small and not conclusive in favor of either surgical or conservative
289
treatment, but an attempt to repair the tendon in cases of laceration or rupture seems justified. In our patient, repair did not restore function of the great toe but the patient was without complaints.
REFERENCES 1. Floyd, D.W., Heckman, J.D., and Rockwood, Jr., C.A.: Tendon lacerations in the foot. Foot Ankle, 48-14, 1983. 2. Frenette, J.P., and Jackson, D.W.: Lacerations of the flexor hallucis longus in the young athlete. J. Bone Joint Surg., 59A673-676,1977. 3. Krackow, K.A.: Acute traumatic rupture of a flexor hallucis longus tendon. Clin. Orthop. Res., 150261-262, 1980. 4. Sarnarco, G.J., and Miller, E.H.: Partial rupture of the flexor hallucis longus tendon in classical ballet dancers. J. Bone Joint Surg., 61A149-150, 1979. 5. Yancey, H.A.: Laceration of the plantar aspect of the foot. Clin. Orthop. Res., 12246-52,1977.
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