Flexor Hallucis Longus Tenosynovitis Research Articles

A cadaveric case study of the fibulo calcaneus internus muscle as a rare accessory muscle of calf region

The fibulocalcaneus (peroneocalcaneus) Internus (FCI) muscle which is also called as Peroneo calcaneus Internus (PCI) muscle (of MacAlister) is a rare variation of calf muscle with a low prevalence of <1%-3% in cadaveric dissection and imaging studies. The FCI arises from the posterior-medial aspect of the distal 1/3 of the fibula, descends posterior and lateral to the flexor hallucis longus (FHL) muscle. It than traverses the tarsal tunnel inferior to the sustentaculum tali of the Calcaneus, and get inserted into the plantar surface of the calcaneus. However, controversy exists concerning the exact location of the insertion site of FCI muscle. Recently the insertion of the FCI muscle has been described as distal to the coronoid fossa, a small depression between the anterior tuberosity and the anterior apex of the sustentaculum tali of the calcaneus. However, chronological descriptions described the FCI as inserting into either the sustentaculum tali itself or a small tubercle on the medical surface of the calcaneus distal to the sustentaculum tali. During routine dissection for under graduate students, about 56-year old Indian male, a Fibulocalcaneus (peroneocalcaneus) Internus (FCI) muscle was identified, which originated from the posterior medial surface of distal third of the fibula and tendon merges with 2 slip of flexor digitorum longus and get inserted on base of distal phalanx of second toe. Knowledge of the FCI muscle is important due its involvement with various ankle pathologies, including predisposing individuals to tarsal tunnel syndrome, FHL tenosynovitis, and posterior ankle impingement and pain. The FCI muscle is one of the least common muscular variants associated with the ankle joint, and it has been implicated in posterior ankle pain and impingement. This muscle is often confused with the flexor digitorum accessorius longus (FDAL) muscle. Additionally, this study describes ways to differentiate between the FCI and FDAL muscles in the lower leg. Radiologists and clinicians should be aware of this anomalous muscle when considering various diagnoses, interpreting radiographs, and pursuing surgical involvement to reduce symptoms of posterior ankle region.

Hindfoot arthroscopy management of flexor hallucis longus tenosynovitis: 24-month outcomes

Objective: We present a series of patients with flexor hallucis longus tenosynovitis submitted to hindfoot endoscopy, describing clinical outcomes and reporting surgical findings and complications seen throughout the treatment. Methods: Thirty-one patients diagnosed with flexor hallucis longus tenosynovitis submitted to posterior ankle endoscopy were followed. The mean follow-up was 24 months. Patients were classified according to American Orthopaedic Foot and Ankle Society (AOFAS) and Visual Analogue Scale (VAS) scores. Patient satisfaction was measured. Results: The mean age of patients was 35.13 (Å} 10.68) years. The VAS score improved from 7.16 preoperatively to 2.16 in postoperative follow-up. The AOFAS score improved from 76.39 (Å} 5.06) preoperatively to 97.10 (Å} 3.78) in postoperative follow-up. Patients were able to return to sports activities at the same level as before surgery by a mean of 4.6 (Å} 1.27) months. One of our patients developed a complication of wound erythema in a portal, which resolved without additional treatment. Conclusion: The diagnosis of flexor hallucis longus tenosynovitis is commonly associated with a large Stieda process or os trigonum impingement, limiting participation in sports activities. In our series, the endoscopic procedure showed good results in treating this condition, promoting a swift return to sports activities. Patients further presented a good postoperative recovery with few complications. Level of Evidence IV; Therapeutics Studies; Cases Series.

Verifying the Insertion of the Fibulocalcaneus (Peroneocalcaneus) Internus Muscle – A Rare Variant Leg Muscle

The fibulocalcaneus (peroneocalcaneus) internus (PCI) muscle is a rare variant leg muscle with a low prevalence of <1%‐3% in cadaveric dissection and imaging studies. The PCI arises from the medial aspect of the distal third of the fibula, descends posterior and lateral to the flexor hallucis longus (FHL) muscle, traverses the tarsal tunnel inferior to the sustentaculum tali of the calcaneus, and inserts into the plantar surface of the calcaneus. However, controversy exists concerning the exact location of the insertion site of the PCI muscle. The insertion of the PCI muscle was recently described as being located distal to the coronoid fossa, a small depression between the anterior tuberosity and the anterior apex of the sustentaculum tali of the calcaneus. However, historical descriptions described the PCI as inserting into either the sustentaculum tali itself or a small tubercle on the medical surface of the calcaneus distal to the sustentaculum tali. During routine dissection of a 53‐year‐old Caucasian male, a PCI muscle was identified, and it inserted into distal to the coronoid fossa on the plantar surface of the calcaneus. More specifically, it inserted into the plantar surface of the calcaneus in the space between the origin of the plantar talonavicular (spring) ligament and the plantar calcaneocuboid ligament. Knowledge of the PCI muscle is important due its involvement with various ankle pathologies, including predisposing individuals to tarsal tunnel syndrome, FHL tenosynovitis, and posterior ankle impingement and pain.

Posterior Hindfoot Endoscopy Using 1.9-mm Diameter Needle Arthroscopy: A Cadaveric Study

Category:Ankle; Arthroscopy; Hindfoot; SportsIntroduction/Purpose:Posterior hindfoot endoscopy is a safe and effective treatment for posterior ankle impingement syndrome (PAIS) and flexor hallucis longus (FHL) tendon disorders. As frequent coexistence of PAIS and FHL tenosynovitis has been reported, it is important to investigate FHL tendon pathology concomitantly when treating PAIS. However, the visualization of FHL tendon distal to the retinaculum is limited when using conventional rigid arthroscopy. Additionally, wound-healing problems following hindfoot endoscopy have been still reported. Recently, a novel 1.9-mm diameter needle-arthroscopic system has been introduced. Its small and semirigid features can help reduce the risk of wound complications and can make it easier to perform FHL tendoscopy. The purpose of this study was to assess whether 1.9-mm diameter needle-arthroscopy was useful for hindfoot endoscopy in a cadaveric model.Methods:A 1.9-mm diameter arthroscopic system (NanoScopeTM, Arthrex) was used to perform a hindfoot endoscopy in 6 human donor ankles (3 pairs). The arthroscope tube is 9.5-cm long and semi-rigid, and has a 1.9-mm outer diameter. The scope's direction of view is 0°, with a 120° field of view. Posteromedial and posterolateral portals were established. Visualization and operative reach with tailored arthroscopic instruments were recorded, including posterolateral talar process, posterior talofibular ligament, intermalleolar ligament, subtalar joint, ankle joint, and flexor hallucis longus (FHL) tendon. Finally, a conventional 4.0-mm diameter arthroscope with a 30° angle was used to compare the visualization of FHL tendon.Results:All significant structures were successfully visualized and reached in all specimens. In ankle joint, all of the tibial surface was visualized, but visualization of talar surface was limited. Due to its wide 120° field of view, there was no difficulty obtaining sufficient visualization in any structures. As this needle-arthroscopic system has the semirigid frame, FHL tendoscopy was easily performed via the posterolateral portal. In all specimens, the FHL tendon was visualized from the level of ankle joint to the Knot of Henry (Zone 1 and 2), and the flexor digitorum longus tendon crossing obliquely over the FHL tendon was observed (Figure). The conventional arthroscope could not be inserted into the tunnel underneath the sustentaculum tali in any specimens.Conclusion:Posterior hindfoot endoscopy using a 1.9-mm diameter needle-arthroscopy provides effective visualization and surgical reach of all significant structures for the treatment of PAIS. Its small and semirigid features also make the FHL tendoscopy less invasive and more accessible than conventional rigid arthroscope.

Five-year follow-up of endoscopic resection of symptomatic os trigonum: a prospective interventional cohort study of a possible cause of ankle and big toe pain

Background: The authors aimed to evaluate the functional outcomes of endoscopic resection and debridement of symptomatic os trigonum and associated inflammatory changes including the flexor hallucis longus (FHL) pathologies. Methods: A prospective interventional study was conducted including 28 patients with 32 symptomatic os trigonum in the period from January 2010 to March 2016. The mean age of patients was 23.6 yr (range, 12 to 45 yr). All patients completed a minimum follow-up of 5 yr. Outcomes were assessed by the 100-mm visual analogue scale (VAS), American Orthopedic Foot and Ankle Society score (AOFAS), and the postoperative complication rate. Results: Endoscopic examination revealed tibiotalar and subtalar hypertrophic synovitis in 14/32 and 13/32 patients, respectively. A small bony prominence encroached upon the FHL in 3/32 patients, 18/32 patients had FHL tenosynovitis, and the FHL tendon was constricted at its entry point into the tarsal tunnel requiring release of the flexor retinaculum in one patient. The mean AOFAS and the VAS scores significantly improved at final follow-up. The degree of improvement of AOFAS and the VAS scores was greater for the posterior ankle impingement group than the os trigonum fracture group. All patients experienced no major complications. Conclusions: Posterior endoscopic excision of a symptomatic os trigonum is safe, feasible, and has excellent results in patients with various sporting or occupational activities. The degree of improvement is greater for patients without os trigonum fracture. Level of Evidence: Level IV.

Ankle Injuries in Dancers.

The term dance encompasses a broad range of different styles; much of the orthopaedic literature has focused on ballet dancers. Injury is common in dancers at all levels, and many serious dancers sustain multiple injuries as they progress through their career. Foot and ankle injuries are among the most common injuries experienced by dancers. These injuries include those that are specific to dancers because of the unique physical maneuvers required to effectively perform, but they can also include common injuries that may require relatively different treatment because of the physical demands of the dancer. Os trigonum syndrome and flexor hallucis longus tenosynovitis generally fall into the former category as they are injuries that are more prevalent in dancers due to the extreme plantarflexion involved in dancing, especially ballet, and the relative demand placed on the toe flexors, most notably the flexor hallucis longus. On the other hand, anterior ankle impingement occurs both in dancers and in the general public. In many cases, a team approach to treatment with knowledgeable physical therapists can obviate the need for surgical treatment. If surgical treatment proves necessary, good results can be achieved with sound surgical technique and a well thought-out rehabilitation program.

Effect of extensive tenosynovectomy on diffuse flexor hallucis longus tenosynovitis combined with effusion.

The objective of this study was to examine the clinical and magnetic resonance imaging (MRI) outcomes of extensive tenosynovectomy on patients with diffuse flexor hallucis longus tenosynovitis combined with effusion (DFHLT-E). Consecutive patients undergoing extensive tenosynovectomy for DFHLT-E in the same foot and ankle center from January 2013 to December 2016 were selected; a total of 14 patients were included in the final analysis. Patients with a minimum 1-year follow-up were evaluated with physical examination, MRI, American Orthopaedic Foot and Ankle Society (AOFAS) clinical midfoot scale, and visual analog scale (VAS) pain scores. The 14 patients were followed up for an average of 15.0 ± 2.3 months (12-18 months). There were no recurrences in all clinical examinations at the final follow-up. The AOFAS score was improved from 61.57 ± 10.70 before surgery to 90.28 ± 9.41 at the final follow-up. The difference was statistically significant (p = 0.001). The VAS score was improved from 4.00 ± 0.82 before surgery to 0.43 ± 0.53 at the final follow-up (p < 0.001). MRI examination revealed two patients with small residual and limited effusion with no clinical symptoms. Superficial pin infection was observed in one patient, and two patients had transient neurostimulation. Extensive tenosynovectomy is an effective alternative for the treatment of DFHLT-E with less complications or recurrence.

Arthroscopic Treatment of Flexor Hallucis Longus Tenosynovitis

Category: Arthroscopy Introduction/Purpose: Flexor Hallucis Longus (FHL) tenosynovitis is a common cause of posterior ankle pain, typically associated with repetitive plantar flexion activities. The purpose of this study was to report the results of patients with FHL tenosynovitis treated with posterior ankle arthroscopy using validated outcome measures and develop a zone-based classification of FHL tenosynovitis that demonstrates well correlated preoperative imaging and intraoperative findings. Methods: Posterior ankle arthroscopy was performed in 11 patients (12 ankles) with a diagnosis of FHL tenosynovitis, with patients followed for a minimum of two years (mean 44 months). Outcomes were evaluated using validated scoring measures, including visual analog scales (VAS) for pain, 12-Item Short Form Health Survey (SF-12), and the Foot and Ankle Ability Measure (FAAM). Results: A zonal classification scheme based on anatomic location was developed, divided into three zones: proximal to the ankle joint, posterior to the ankle joint, and from the fibro-osseous tunnel underneath the sustentaculum tali to the FHL insertion. Agreement between preoperative MRI and arthroscopic zonal involvement at time of surgery was present in ten feet (83%), and differed in two feet (17%). VAS scores improved significantly from 7.1 ± 1.4 preoperatively to 1.3 ± 1.3 postoperatively (p &lt;0.001). Mean values for ADL and sports subscales of the FAAM at time of follow up were 87.1 ± 16.2 and 76.5 ± 28.8, respectively. Physical component summary (PCS) and mental component summary (MCS) of the SF-12 yielded means of 51.3 ±12.8 and 52.7 ± 5.0, respectively. Conclusion: FHL pathology can be classified using a zone-based classification scheme, which is highly correlative between preoperative MRI and intraoperative findings. Posterior ankle arthroscopy is an effective treatment option for FHL tenosynovitis, as evaluated using validated outcome measures.

Treatment of hindfoot and ankle pathologies with posterior arthroscopic techniques.

The two-portal hindfoot arthroscopy is an effective procedure enabling direct visualisation of posterior ankle pathology with low invasiveness.An important stage of the hindfoot endoscopy is localisation of the flexor hallucis longus (FHL) tendon to protect the neurovascular bundle which is located just medial to it.Posterior ankle impingement syndrome and FHL tenosynovitis are common causes of posterior ankle pain and frequently occur together.Posteriorly localised talar osteochondral lesions, Achilles tendon disorders, osteoarthritis, talar bone cysts and talar fractures are among the other pathologies that can be treated with hindfoot arthroscopy.Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160055. Originally published online at www.efortopenreviews.org

Role of ultrasonography in assessment of tendons around ankle joint

Introduction Ankle injury is a common condition secondary to trauma; ultrasonography plays a big role in the assessment of a variety of musculoskeletal disorders. These improvements along with economic factors and availability have resulted in renewed interest in using ultrasound (US) as a diagnostic tool. As such, the efficacy of US has been compared with other modalities, in particular MRI, as a cost effective imaging alternative. Context US is a rapid, accurate, and cheap diagnosing tool. Aims The aim of this study was to show the efficacy of US as a cost effective diagnostic imaging alternative. Settings and design Selected individuals of ankle or foot injuries by clinical examination, with no exclusion criteria. Performing real time ankle US bilaterally for each patient. Participants and methods They will be divided into two groups: first control group which demonstrates 25 asymptomatic ankle ligaments and tendons. Second group includes 25 patients suffering from unilateral or bilateral ankle as sequelae of trauma. All patients will be subjected to history taking and real-time high-resolution ultrasonography. The procedures followed were in accordance with the ethical standards and approval by Benha University. Statistical analysis used Parametric analysis of our results using Excel program. Results Forty pathological entities were diagnosed by both utilized imaging modalities in 25 cases. The study included 11 cases with tendon pathology that were interpreted into 13 pathological entities by all imaging modalities. However, US missed two cases: (a) a case of partial tear of Achilles tendon; (b) a case of flexor hallucis longus tenosynovitis. US could detect all of the ligamentous lesions identified in three cases, which were interpreted as tear by MRI, likely due to US anisotropy effect. Conclusion Ankle US is a rapid, accurate, and cost effective imaging modality.

Arthroscopic Release of Flexor Hallucis Longus Tendon Sheath in Female Ballet Dancers: Dynamic Pathology, Surgical Technique, and Return to Dancing Performance

Stenosing tenosynovitis of the flexor hallucis longus (FHL) tendon is known as a major overuse lesion in female dancers. We describe arthroscopic surgical techniques in relation to the dynamic pathology of the disease. Crepitus and pain on moving the great toe with the ankle in plantar flexion on preoperative examination confirm the diagnosis of FHL stenosing tenosynovitis even if the os trigonum is not evident. The ankle is approached through standard posterolateral and posteromedial portals. A 4.0-mm-diameter 30° arthroscope is used. Soft tissues around the talus are cleared with a motorized shaver and a radiofrequency device. The posterior aspects of the talus, os trigonum, and FHL tendon surrounded by the tendon sheath are visualized. The dynamic pathology of the FHL tendon is well observed on passive motion of the great toe. The prominent bone fragment of the talus is removed and the tendon sheath is cut with a retrograde knife and a motorized shaver from the superior border down to the entrance of the fibro-osseous tunnel. Arthroscopic release of the FHL tendon sheath is a useful and easy method to directly approach the dynamic pathology of FHL tenosynovitis in female ballet dancers.

Anatomical characteristics of the flexor digitorum accessorius longus muscle and their relevance to tarsal tunnel syndrome a systematic review.

Clinical and cadaver studies have reported that supernumerary muscles could be the etiology of a variety of pathologic disorders, such as posterior impingement syndrome, tarsal tunnel syndrome (TTS), and flexor hallucis longus tenosynovitis. We describe a unique variant of the flexor digitorum accessorius longus (FDAL) muscle as an apparent cause of TTS, functioning as an independent flexor of the second toe, which has not been described in the literature. In addition to this case report, a systematic review was performed of TTS caused by the FDAL muscle. A targeted search of PubMed, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature, and Web of Science identified full-text papers that fulfilled the inclusion and exclusion criteria. Twenty-nine papers were identified for inclusion in the systematic review: 12 clinical papers of TTS caused by the FDAL muscle and 17 cadaver-based papers. Clinicians often do not include the FDAL muscle in the differential diagnosis of TTS. This literature review suggests that the FDAL is an important muscle in terms of its functional and clinical significance. Knowledge of this muscle, its anatomical location and variations, and its magnetic resonance imaging characteristics may help clinicians make an accurate differential diagnosis.

Imaging study of ankle injury in professional soccer player of males

To analyze the imaging abnormal findings of ankle injuries in professional soccer player of males. The thirty-two professional soccer players in local region soccer club had been selected as research objects from March 2014 to January 2015, and all were men. Average age was 22.03±3.0 years old (19-33 years); the average age was 8.6±2.0 years old that began to engage in professional football training, and average time of engaged in football sports was 13±4 years (7-27 years). X-ray examination was used VM DR (Philips Co.), anteroposterior and lateral position of ankle joints. CT scan was used MSCT of 64 rows detector (Aquilion 64, TOSHIBA Co.). After routine scan, raw data was transmitted to the workstation and then reconstructed to be axial, sagittal, coronal imaging. MR examination was used 1.5 T superconducting equipment system (Achieva Dual, Philips Co.) and with ankle joint special phased array coil. TSE sequence be used to scan routine axial T2-weighted imaging; coronal T1-weighted imaging; coronal PWI; and sagittal T2-weighted imaging with fat suppressed. The sagittal PWI scan was used with Isotropic with fat suppressed FFE sequence. The X-ray examination was finished for 28 person and 51 ankle joints. 26 person and 52 ankle joints were completed CT scan and reconstructed imaging for all joints. MR examination was finished in 30 person and 51 ankle joints. On X-ray and CT display that the abnormal changes of the talus is most commonly found that the incidence of "dolphin mouth" like protrusion at posterior edge was 35 ankles (rate of occurrence was 68.6%), the triangle prominence at out edge was 45 ankles (rate of occurrence was 88.2%). It also was found that 8 lateral malleolus have osteophytes, 5 ankles have medial malleolus osteophytes and 12 ankles have loose bodies at posterior ankle. MRI showed that 30 ankles were the anterior talofibular ligaments injury and incidence was 58.82%, 26 ankles were posterior talofibular ligaments injury (incidence was 51.0%), 25 ankles were calcanofibular ligaments injury (incidence was 49.0%), 29 ankles was the synovitis and local effusion at posterior ankle (incidence was 56.9%), the partial ligaments injured of deltoid ligaments were usually found and entirely torn were very rare (only three ankles). The former groups and shallow ligaments of deltoid ligaments were prone to injury. The common tendon disease of injury was tenosynovitis, 18 flexor hallucis longus tenosynovitis, 13 posterior tibialis tenosynovitis,7 flexor digitorium tenosynovitis, 5 peroneus longus tenosynovitis, 2 peroneus brevis tenosynovitis and 6 Achilles tendinopathy. Tendinosis and tendon degeneration was relatively rare. The professional soccer players have been easily lead to the anatomic abnormal and pathological changes in the bones, ligaments and tendons due to long-term training and competition. The majority changes were chronic injury. Imaging examination can be found the abnormal changes of ankle and could help athletes, coachs, doctors to understand and assess the ankle structure and functional status.

The anatomic variations of the posterior talofibular ligament associated with os trigonum and pathologies of related structures.

The aim of this study is to investigate the detailed anatomy of the posterior talofibular ligament (PTFL) on MR images in patients with os trigonum. We also evaluated the pathological conditions of the PTFL, anterior talofibular ligament (ATFL), flexor hallucis longus (FHL) tendon, talus and os trigonum. Ankle MRIs of 70 patients with os trigonum (study group) and 70 patients without it (control group) were reviewed for the anatomy of the anterior and posterior fibers of PTFL. The prevalence of PTFL and ATFL pathologies was also compared between two groups. Additionally FHL tenosynovitis and osseous pathologies were evaluated. The posterior fibers inserted into the lateral tubercule of the posterior process of the talus in the control group whereas if an os trigonum was present, the posterior fibers of PTFL were inserted only into the os trigonum. The origins of anterior and posterior fibers were the medial surface of the lateral malleolus and the insertion of the anterior fibers was lateral surface of the talus posterior to the lateral malleolar facet in both groups. There was a significant association between an abnormal PTFL, ATFL and the presence of os trigonum. FHL tenosynovitis was higher in the study group but it did not meet the statistical significance. The most common pathology of the talus and os trigonum was subchondral edema along the synchondrosis. In patients with os trigonum, the posterior fibers of the PTFL were inserted herein. In the case of an os trigonum signal alterations of ligaments were more common, which may reflect chronic instability.

Ultrasonographic Evaluation of Flexor Hallucis Longus Tenosynovitis in Sports Players

The purpose of this study was to investigate the ultrasonographic features of flexor hallucis longus (FHL) tenosynovitis in sports players. High-resoluted ultrasound was used to measure the thickness and echogenicity of the flexor hallucis longus at the posteromedial ankle, especially the fibro-osseous tunnel, for 60 sports players (120 feet). They were compared with their asymptomatic feet. There were two group; group 1 was symptomatic feet, 2 was asymptomatic. The 36 males (72 feet) and 24 females (48 feet) had an average age of 21.3 years (range, 18–23 years). Thickness, echogenicity of the tendon on each group were evaluated by the ultrasonography and the results were statistically analyzed. The mean thickness of the FHL on group 1 was 3.4±1.2 mm, 2.1±1.3 mm on group 2. There was significant difference between two groups (p=0.002). The thickness of FHL based on gender and location was not significant different (p>0.05). For group 1, increased thickness of the FHL and reduced echogenicity, peritendious fluid collection were observed in ultrasonographic findings.Increased thickness (>3 mm) and hypoechoic lesion, peritendinous fluid collection of the tendon were sonographic findings at the posteromedial ankle in the FHL tenosynovitis. The authors suggested that Ultrasonography is a valuable and alternative tool for the evaluation of FHL tenosynovitis.

Arthroscopic Treatment of Tenosynovitis of the Flexor Hallucis Longus Tendon

Tenosynovitis of the flexor hallucis longus (FHL) tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. A traumatic cause for this situation, such as an ankle sprain, is considered rare. In case of failure of conservative treatment, the tendon can be surgically released, which is usually done through an open procedure. This article presents the results of an arthroscopic release of the FHL. Twenty-seven patients underwent surgery for FHL tenosynovitis over a period of 18 months. The mean age of the patients was 34 years. All patients related the onset of the condition with an ankle sprain. Eighteen patients were on worker's compensation and five had sport-related accidents. None of the patients was a professional athlete or a ballet dancer. The mean follow-up was 32 months. The outcome was measured with a satisfaction questionnaire and with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system. The mean postoperative AOFAS score was 89 with 70% excellent or good results. Mean satisfaction rate was 4 (range, 0 to 5); 89% of the patients would undergo the procedure again. Twenty-two patients (81%) returned to the same level of activity in work and sports. A complication rate of 18% (five patients) and reoperation rate of 4% (one patient) were found. Arthroscopic release of the FHL tendon was a valid procedure. It was a minimally invasive surgery that allowed good visualization of the involved structures and yielded good results. This condition can be related to trauma and is not an exclusive disease of ballet dancers or overuse.

Endoscopic treatment of posterior ankle pain

The aim of this study is to describe the indications for two-portal hindfoot endoscopy in the treatment of posterior ankle compartment pathologies and to express the effectiveness of this technique by short- to mid-term outcomes on 59 consecutive patients. In our institute, between 2003 and 2009, patients operated by single surgeon with hindfoot endoscopy were enrolled. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot and Maryland foot scores (MFS) were obtained preoperatively and postoperatively. In the final follow-up, besides the scores, patients were asked whether they were satisfied and whether they would elect this treatment again. The indications for 59 patients were posterior ankle impingement syndrome (14), osteochondral lesion of talus (13), isolated flexor hallucis longus (FHL) tenosynovitis (11), synovial osteochondromatosis (2), pigmented villonodular synovitis (2), peroneal tenosynovitis (4), subtalar joint arthrosis (4), tibiotalar arthrosis (4), intraosseous talus cyst (4; 1 bilateral), and talus fracture (1). FHL tendon was affected in all cases, and tenolysis was performed for each patient. The mean preoperative AOFAS-hindfoot scores increased from 56.7 ± 14.5 to 85.9 ± 12.5 (P < 0.0001), and the mean preoperative MFS increased from 54.8 ± 17.5 to 84.9 ± 15.9 (P < 0.0001), postoperatively. Four patients with posttraumatic arthritis were dissatisfied. Two sural nerve-related complications were identified. Hindfoot endoscopy was demonstrated to be a safe and effective procedure for the treatment of various hindfoot pathologies in this cohort, excluding patients with posttraumatic arthritis. Our results show that the prevalence of FHL tenosynovitis may be higher than previously reported and should always be considered in differential diagnosis of posteromedial ankle pain. Case series with no comparison group, Level IV.

Hindfoot endoscopy for accessory flexor digitorum longus and flexor hallucis longus tenosynovitis

We present a case report involving the flexor digitorum accessorius longus (FDAL) tendon which travels through a fibro-osseous tunnel together with the flexor hallucis longus (FHL) tendon, causing a stenosing tenosynovitis. The patient was admitted with posteromedial ankle pain and diagnosed clinically as FHL tenosynovitis. We found two tendons in the tunnel during hindfoot endoscopy. The stenosis was relieved by endoscopic debridement. After the operation, we checked the MRI images and observed two tendons. We concluded that the accessory tendon was the FDAL. Two years later the patient was admitted with the same symptoms. We excised the FDAL muscle and the patient's symptoms resolved. The FDAL muscle is a cause of FHL tenosynovitis. Because of its variability and mostly asymptomatic nature, it may not be noticed it on an MRI scan. Hindfoot endoscopy is a safe tool for the diagnosis of this condition and curative treatment is afforded by excision of the FDAL muscle.

A 17-Year-Old Ballet Dancer with Medial Ankle Pain

A 17-Year-Old Ballet Dancer with Medial Ankle Pain

Posterior Ankle Impingement Syndrome

Posterior ankle impingement syndrome is a clinical disorder characterized by posterior ankle pain that occurs in forced plantar flexion. The pain may be acute as a result of trauma or chronic from repetitive stress. Pathology of the os trigonum-talar process is the most common cause of this syndrome, but it also may result from flexor hallucis longus tenosynovitis, ankle osteochondritis, subtalar joint disease, and fracture. Patients usually report chronic or recurrent posterior ankle pain caused or exacerbated by forced plantar flexion or push-off maneuvers, such as may occur during dancing, kicking, or downhill running. Diagnosis of posterior ankle impingement syndrome is based primarily on clinical history and physical examination. Radiography, scintigraphy, computed tomography, and magnetic resonance imaging depict associated bone and soft-tissue abnormalities. Symptoms typically improve with nonsurgical management, but surgery may be required in refractory cases.