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Background: Achilles tendon rupture is a common and primary cause of lower limb tendon injuries suffered during sports-related activities. The causes of Achilles tendon rupture include calf muscle and tendon overuse, steroid local injection in tendon, poor tendon quality, and various medical conditions. Historically, acute Achilles tendon rupture was treated conservatively. However, historical techniques are now associated with an increased risk of rerupture. Aim and Objective: To study of the reconstruction of chronic tendoachilles ruptures with the flexor hallucis longus and peroneus brevis. Material and Method: 30 patients aged between 30 and 60 years underwent reconstruction of chronically ruptured tendon Achilles either with flexor hallucis longus or peroneus brevis. Ruptures are due to stumbling in fields, falling from stairs, and some being uneventful. All these patients attended the department of Orthopaedics OPD and tertiary care of SSIMS, Bhilai. The patients were admitted and surgically treated after appropriate counseling and consent. The results were compared with the Quigley scale and Leppilahti scores. Results: Rupture of the Achilles tendon is more common in middle-aged males. Delay in diagnosis is due to a lack of adequate knowledge by the treating physician and a lack of immediate disability for the patient. The Thompson test has high sensitivity and specificity in diagnosis. Complications such as superficial skin infections and wound dehiscence are more common in patients treated with peroneus Peroneus and Sensory disturbance on foot is post operative complication. Conclusion: Flexor hallucis longus is superior to Peroneus brevis because of its anatomical and technical advantages, less incidence of superficial infections, wound dehiscence, and sensory disturbance, and better weight-bearing times and functional recovery. [ABSTRACT FROM AUTHOR]

Background: Pain in the hallux metatarsophalangeal joint (MTPJ) is very common, yet the underlying etiology remains unknown. Previous clinical research and biomechanical research has implicated stenosing flexor hallucis longus (FHL) tendonitis as a possible cause. The hypothesis of this study was that treatment solely focusing on alleviating restricted FHL excursion would be beneficial in patients with hallux MTPJ pain. Methods: This is a retrospective study of those treated in the Foot & Ankle Division between January 2009, and December 2018, who were diagnosed with FHL tendonitis with associated pain in the hallux MTPJ. Demographics, comorbidities, examination findings, imaging results, pain scores, treatment instituted, and outcome was obtained from the electronic medical record. The primary outcome was the improvement in the pain score (visual analog scale [VAS]). The surgical patients were included if their procedure was solely related to the FHL (posteromedial ankle release ± os trigonum resection). The decision to have surgery was analyzed by univariate and multivariable statistics using demographics, comorbidities, and clinical findings as potential factors (P <.05). Results: In 75% (59 of 79 feet), nonoperative treatment of FHL stenosis resulted in a decrease in pain scores that the patients felt was satisfactory. The operative group that had an FHL release showed decreased pain in 90% (18 of 20 feet). Multivariable analysis identified the need for immobilization (OR 9.8, 95% CI 1.8-55.2, P =.009), participating in athletics (OR 8.7, 95% CI 1.8-42.2, P =.007), and higher initial VAS (OR 1.7, 95% CI 1.3-2.3, P <.001) as being associated with the decision for surgery. Conclusion: Previous biomechanical studies have suggested that stenosing FHL synovitis can cause increased intraarticular loading in the hallux MTPJ. The current clinical study supports this hypothesis, demonstrating that treatment focused on relieving restricted FHL excursion can ameliorate pain in the hallux MTPJ in select cases. [ABSTRACT FROM AUTHOR]

This case report presents a novel cause of rigid flatfoot caused by the entrapment of the Flexor Hallucis Longus (FHL) tendon within the subtalar joint. A 19-year-old male with chronic right ankle and foot pain diagnosed with rigid flatfoot deformity. MRI identified the FHL tendon entrapped within the subtalar joint, a condition to our knowledge never previously reported. This report highlights the importance of thorough clinical evaluation and advanced imaging techniques in diagnosing rare causes of rigid flatfoot and suggests that surgical options may still be valid for such rare presentations.

Case: An overall healthy 48-year-old man suffered a left foot mangled crush injury resulting in a post-transmetatarsal amputation and subsequently developing a painful neuroma on the plantar surface of the foot. To avoid the zone of injury, targeted muscle reinnervation was used to treat the neuroma by coapting the tibial nerve to the motor point of the flexor hallucis longus (FHL) muscle. At 1-year follow-up, the patient reported no pain at rest, returned to work, and could ambulate with an orthosis for 30 minutes. Conclusion: Rare tibial nerve coaptations to the FHL could serve as a treatment option for patients with neuromas in traumatic postmetatarsal amputation. [ABSTRACT FROM AUTHOR]

BACKGROUND: The intrinsic foot muscles play an important role in medial longitudinal arch support, as well as several extrinsic foot muscles. While various strength training methods specific to intrinsic foot muscles have been conducted, these exercises are associated with certain concerns regarding their effectiveness and difficulty. We developed a new exercise for the intrinsic muscles (MTP flexion exercise). OBJECTIVE: The aim was to compare the shear modulus of the toe flexors as the muscle contraction activity during MTP flexion and short-foot exercises using ultrasound shear wave elastography. METHODS: Eleven healthy participants were included in this study. The shear modulus of the toe flexor muscles was measured during MTP flexion and short-foot exercises using ultrasound shear wave elastography. The muscle shear modulus was statistically compared between the resting phase, and during the two exercises. RESULTS: The shear modulus during MTP flexion exercise was significantly greater than in the resting phase in the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, quadratus plantae, and flexor digitorum longus. The flexor digitorum longus showed greater shear modulus during MTP flexion exercise than during short-foot exercise. CONCLUSION: MTP flexion exercise showed equivalent or greater contraction activity in certain intrinsic and extrinsic foot muscles when compared with short-foot exercise. This exercise is considered one of the training options for strengthening the intrinsic muscles of the foot. [ABSTRACT FROM AUTHOR]

Background: Clinicians and researchers are beginning to pay attention to the importance of the intrinsic foot muscles (IFMs). Among IFMs, the abductor hallucis (AbH) is associated with foot disorders. However, so far no method for assessing the strength of the AbH has been established. In addition, previous studies have shown increased IFM activity in the plantarflexed position of the ankle. Therefore, this study tests the hypothesis that a correlation will be found between the cross-sectional area (CSA) of the AbH and the flexion torque and that the first metatarsophalangeal (MTP) joint would be stronger in the plantarflexed (PF) position of the ankle joint than in the neutral (N) position. Methods: Eight male and 8 female patients (16 lower limbs) were included in this study to measure the CSA of IFM and the extrinsic foot muscles of the lower leg. Furthermore, the flexion torque of the first MTP joint was measured using a handheld dynamometer at the N and PF positions of the ankle joint. Correlation analysis was performed to examine the relationship between the CSA of each muscle and the flexion torque of the first MTP joint in the N and PF positions. Results: In the N position, a correlation was found between the flexion torque of the first MTP joint and the CSA of the AbH (r = 0.818), flexor hallucis brevis (r = 0.730), and flexor hallucis longus (r = 0.726). In the PF position, a correlation was found between the flexion torque of the first MTP joint and the CSA of the AbH (r = 0.863) and flexor hallucis brevis (r = 0.680). (P <.05) Conclusion: Overall, this study suggested that by measuring flexion torque of the first MTP joint in the PF position, AbH strength can be estimated without using any expensive equipment. Level of Evidence: Level V, mechanism-baced reasoning. [ABSTRACT FROM AUTHOR]

Background: Chronic Achilles tendinopathy following Haglund disease is a common ankle condition that is difficult to manage. In this study, we will compare the clinical outcomes of debridement and ostectomy with and without FHL tendon transfer in treating Haglund deformity. Methods: Forty eligible patients aged >50 years who did not respond to conservative treatment were randomly divided into 2 groups for surgical approach: using flexor hallucis longus (FHL) tendon transfer (FHL group) or "standard procedure" (control group). The main surgical treatment included debridement and ostectomy. AOFAS and VISA-A scores were obtained from all patients pre- and postoperatively. Results: Twenty patients were assigned to each of the 2 groups and were observed for at least 1 year. The American Orthopaedic Foot & Ankle Society (AOFAS) ankle hindfoot scores and the Victorian Institute of Sports Assessment self-administered Achilles (VISA-A) questionnaires scores improved more in the FHL group; however, the average difference in the change in scores did not reach the levels previously reported for minimal clinically important differences. Surgical complications and hallux function were not significantly different between the 2 groups. Conclusion: We found that FHL tendon transfer may improve the clinical outcome scores of Achilles tendon treatment in patients aged >50 years using debridement and ostectomy. However, tendon transfer increases the time of surgery and creates additional skin incisions, which may cause more short-term wound complications, and the significance of the differences in outcome improvement may not be clinically meaningful. Level of Evidence: Level II, grade A recommendation. [ABSTRACT FROM AUTHOR]

This report presents a unique case of checkrein deformities in both halluces following isolated intramuscular sarcoidosis, a rare occurrence given the infrequent musculoskeletal involvement in sarcoidosis. Typically resulting from flexor hallucis longus tendon entrapment by scar tissue post-trauma, the checkrein deformity reported in this paper presented with unusual metatarsophalangeal joint flexion and interphalangeal joint extension during ankle dorsiflexion. A 49-year-old woman with a history of intramuscular sarcoidosis presented with a great toe deformity and discomfort while wearing shoes, leading to a diagnosis of dynamic deformity, possibly attributed to tendon tethering by sarcoidosis. Surgical treatments, including abductor hallucis muscle intratendinous tenotomy, flexor hallucis longus Z-plasty lengthening, Weil osteotomy, and Kirschner wire fixation, significantly improved the functional scores and patient discomfort. This report underscores the importance of recognizing dynamic deformities and the potential for rare diseases, such as sarcoidosis, to cause such conditions, highlighting the need for careful diagnosis and tailored surgical intervention for atypical checkrein deformities. [ABSTRACT FROM AUTHOR]

Background: This study aimed to investigate the incidence of toe flexion deformity after fibular free flap transplantation and to analyze the etiology of the deformity. Methods: Fifty patients underwent vascularized fibular free flap transplantation were retrospectively included. Statistical analysis examined correlations between deformity occurrence and resected fibula length and residual distal fibula length using the χ2 test. Doppler ultrasound and anatomical evaluations were conducted. Results: Flexion deformity of the first toe was observed in all patients (100%), exacerbated by ankle dorsiflexion. χ2 test revealed no significant correlation between fibula length, distal residual fibula length, and flexion deformity. Doppler ultrasound revealed elevated echoes and blurred textures in the flexor hallucis longus post‐fibular transplantation, while anatomical evaluation confirmed the peroneal artery as its primary nutrient supplier. Conclusion: This study reports a 100% incidence of toe flexion deformity post‐transplantation. The deformity correlated strongly with ischemic contracture of the flexor hallucis longus. [ABSTRACT FROM AUTHOR]

Pigmented villonodular synovitis is an uncommon benign neoplastic proliferation associated with the synovium, bursa, or tendon sheaths; most commonly occurring in the third to fourth decade of life. It is rare in children and may be painful or painless. Magnetic resonance imaging is the diagnostic study of choice. In this report, the radiologic, ultrasound, and magnetic resonance imaging findings of pigmented villonodular synovitis of the flexor hallucis longus in a 12-year-old girl are discussed. We briefly review the surgical findings as well. To our knowledge, this is the first case report that simultaneously synthesizes the imaging findings of 3 diagnostic imaging modalities for optimal visualization and is the youngest reported case of pigmented villonodular synovitis of the flexor hallucis longus tendon.

Purpose: The unique demands of dance technique make dancers more prone to certain pathologies especially of the foot and ankle. Flexor hallucis longus (FHL) tendinopathy, colloquially known as "dancer's tendinopathy," is common in dancers and not well studied. The purpose of this study was to assess if morphological alterations in tendon structure occur as an adaptive response to dance activity by comparing the FHL tendon in dancers to non-dancers, and if pathology further alters tendon morphology in dancers clinically diagnosed with tendinopathy. Methods: Three groups of ten participants were recruited (healthy non-dancers, healthy dancers, and dancers with FHL tendinopathy). Ultrasound images of the FHL tendons were analyzed for macromorphology by measuring the tendon thickness. The micromorphology was analyzed by determining the peak spatial frequency radius of the tendon. Our study did find increased tendon proper and composite tendon thickness in dancers with tendinopathy but no difference between asymptomatic dancers and non-dancers. Results: There was no significant difference in micromorphology found between any of the groups. As expected, dancers with tendinopathy demonstrated increased composite tendon and tendon proper thickness however, there was no evidence of adaptive thickening of the FHL tendon as might be expected for the dance population. There was also no evidence of micromorphological changes in the presence of clinically diagnosed FHL tendinopathy. Conclusion: Because of the limited normative data for this pathology, these results can help improve diagnosis and therefore treatment for dancers to decrease the impact of this injury on their careers. [ABSTRACT FROM AUTHOR]

Achilles tendon ruptures are fairly common injuries that are often unfortunately missed, leading to the development of chronic tendoachilles (TA) ruptures. Patients present with gait abnormalities and significant ankle plantarflexion weakness. Imaging modalities such as ultrasound (US) and magnetic resonance imaging (MRI) are used to confirm the diagnosis and help in surgical planning. Most chronic TA ruptures require surgical management, with non-operative management being reserved for medically unfit patients due to generally poor outcomes. A multitude of surgical reconstruction options have been described in the literature, each with its benefits and disadvantages. Ultimately, the choice of surgical technique depends on the residual gap that is present following debridement of the scar tissue that forms a bridge between the ruptures ends of the Achilles tendon, graft availability and the treating surgeon's preference. Surgery results in an improvement in patient-reported outcomes, with the majority going back to their pre-injury level activities. However, surgery is also associated with a fair number of complications, the most common being wound healing problems, infections, neurological injury and deep vein thromboses for which patients need to be appropriately counselled for. [ABSTRACT FROM AUTHOR]

The foot core system is essential for upright stability. However, aging‐induced changes in the foot core function remain poorly understood. The present study aimed to examine age‐related differences in postural stability from the perspective of foot core capacity and neuromuscular control during quiet standing. Thirty‐six older and 25 young adults completed foot core capacity tests including toe flexion strength, muscle ultrasonography, and plantar cutaneous sensitivity. The center of pressure (COP) and electromyography (EMG) of abductor hallucis (ABH), peroneus longus (PL), tibialis anterior (TA) and medial gastrocnemius (GM) were simultaneously recorded during double‐leg and single‐leg standing (SLS). EMG data were used to calculate muscle synergy and intermuscular coherence across three frequency bands. Compared to young adults, older adults exhibited thinner hallucis flexors, weaker toe strength, and lower plantar cutaneous sensitivity. The ABH thickness and plantar cutaneous sensitivity were negatively associated with the COP mean peak velocity in older adults, but not in young adults. Besides, older adults had higher cocontraction of muscles spanning the arch (ABH‐PL) and ankle (TA‐GM), and had lower beta‐ and gamma‐band coherence of the ABH‐PL and TA‐PL during SLS. Foot core capacities became compromised with advancing age, and the balance control of older adults was susceptible to foot core than young adults in balance tasks. To compensate for the weakened foot core, older adults may adopt arch and ankle stiffening strategies via increasing muscle cocontraction. Furthermore, coherence analysis indicated that aging may increase the demand for cortical brain resources during SLS. [ABSTRACT FROM AUTHOR]

Background: A number of studies have reported that calf muscle atrophy is a common long-term problem after Achilles tendon repair; however, there is still a lack of data concerning early postoperative morphological changes in the calf muscle after surgery. Purpose: To investigate changes over time in calf muscle volume and fatty degeneration during 1 year after Achilles tendon repair. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective 1-year serial magnetic resonance imaging study was carried out with 20 patients who underwent tendon repair for unilateral acute Achilles tendon rupture. The magnetic resonance imaging assessment in addition to clinical and functional evaluations was performed at 1, 3, 6, and 12 months after surgery. The muscle volume of the medial and lateral gastrocnemius, soleus, and flexor hallucis longus (FHL) and fatty degeneration of the medial and lateral gastrocnemius and soleus were measured for the calf muscles, and the relative volume and fatty degeneration changes in the affected leg compared with the healthy contralateral leg were calculated as a percentage ([injured/healthy control] × 100) to assess structural changes over time. Results: Muscle volumes of the medial gastrocnemius, lateral gastrocnemius, soleus, and FHL were 92.3%, 92.8%, 84.6%, and 95.9% at 12 months after surgery, respectively. Medial and lateral gastrocnemius and FHL muscle volumes improved over time and recovered to almost equal to that of the healthy side at 12 months after surgery. The soleus muscle volume did not recover significantly over time and was statistically significantly smaller than that of the healthy side at 12 months (P =.029). Fatty degeneration rates of the medial gastrocnemius, lateral gastrocnemius, and soleus were 118.2%, 113.9% and 121.1% at 12 months after surgery, respectively. Fatty degeneration of the medial and lateral gastrocnemius did not change significantly, but there was a statistically significant increase in fatty degeneration of the soleus over time (P <.001). Conclusion: Within the triceps surae muscle, the soleus was the most negatively affected by injury and repair for both muscle volume and fatty degeneration. Postoperative management to recover the soleus muscle function before a return to sporting activities should be considered in the future. [ABSTRACT FROM AUTHOR]

Arthrokinematics (caudal and posterior movements of the talus) and posterior soft tissues of the ankle during ankle dorsiflexion have not been objectively evaluated in detail. This study aimed to investigate the characteristics of arthrokinematics and posterior soft tissues of the ankle during ankle dorsiflexion using ultrasound. Thirteen healthy adults participated in the study. Participants whose passive dorsiflexion range of motion (ROM) of the ankle joint was <35° were classified as the restricted group (n = 6), and participants whose passive ankle dorsiflexion ROM was ≥35° were classified as the control group (n = 7). Passive ankle dorsiflexion was performed to measure the ankle arthrokinematics. Strain elastography was performed to measure the elasticity of the flexor hallucis longus (FHL) and Kager's fat pad (KFP) at each dorsiflexion angle. A significant difference in the posterior movement of the talus at the ankle dorsiflexion of 30° was observed between the two groups (P = 0.04). The elasticity of the restricted group was increased at all angles in both FHL and KFP (P < 0.05). This study showed that it is possible to objectively evaluate the direction of ankle arthrokinematics and posterior ankle soft-tissue restrictions using ultrasound. [ABSTRACT FROM AUTHOR]

Acute Achilles tendon rupture is a common injury and when missed leads to the development of a chronic Achilles tendon rupture. Studies suggest surgical treatment (either repair or reconstruction) for most patients with a chronic Achilles rupture due to the functional deficit caused by the lack of an intact Achilles tendon. Numerous autograft options such as the flexor hallucis longus, hamstrings, peroneal and quadriceps tendon have been used to reconstruct the Achilles tendon, either as a tendon transfer or as an interposition graft. The choice of autograft used usually depends on the size of the defect left after debridement of the Achilles tendon edges, but is often dictated by surgeon preference and tissue availability. Currently, there is no consensus as to the best autograft option. The aim of this study was to evaluate the various autograft options used to reconstruct the Achilles tendon, and the advantages and disadvantages of using each tendon, focussing specifically on the harvesting technique, anatomical and biomechanical properties. This was done by reviewing the current published literature, supplemented by carrying out anatomical dissection in the cadaveric lab. The flexor hallucis longus is synergistically related to the Achilles tendon and biomechanically strong, however harvesting can result in weakness in big toe flexion. The peroneus brevis whilst being biomechanically strong is a much shorter tendon compared to the other autograft options. Similarly, the quadriceps tendon is also a strong tendon option, but may not be appropriate for larger chronic Achilles tendon rupture gaps. The semitendinosus tendon can be tripled/quadrupled to resemble the Achilles tendon, but is associated with higher risks of patient morbidity when harvesting the tendon. Treatment of chronic Achilles tendon ruptures remains a challenge. Each autograft option has its own unique advantages and disadvantages which should be considered on a case-specific basis. Further work is required to analyse the biomechanical properties of the autograft options to determine if one option is superior. [ABSTRACT FROM AUTHOR]

BACKGROUND: Intrinsic foot muscle (IFM) dysfunction and poor foot arch are associated with various foot conditions. Toe flexor exercise (TFE) has been used to improve it; however, the immediate effects of TFE on each IFM and how it relates to changes in navicular bone height (NH) are unclear. OBJECTIVE: This study aimed to investigate acute muscle swelling in the IFM after TFE and the association between changes in NH and IFM size. METHODS: Fourteen adults participated in this study. NH and cross-sectional area (CSA) of the IFM were acquired pre and post- TFE. The CSA of the IFM, including the abductor hallucis (AbH), flexor hallucis brevis, flexor digitorum brevis, and quadratus plantae, was acquired with ultrasonography. In the TFE, each participant completed five sets of eight repetitions with maximum strength. RESULTS: The NH and CSA of all IFM significantly increased significantly post-TFE (p < 0.01). Only the increase in AbH was moderately and positively correlated with the change in NH (r = 0.54, p < 0.01). CONCLUSION: This study suggests that the acute swelling of AbH after TFE is associated with an immediate increase in NH, supporting the important role of AbH in the formation of foot arch. [ABSTRACT FROM AUTHOR]

Background: The tendons of the flexor hallucis longus (FHL) and flexor digitorum longus (FDL) are commonly utilized in reconstructive foot surgery to address deformities. These tendons intersect on the plantar surface and exhibit varying interconnections that can significantly impact graft length and complicate the tendon harvesting process. The objective of this study was to comprehensively categorize these interconnections using a modified classification system and precisely determine their positional relationships with surgically significant bony landmarks. Methods: Sixty embalmed feet of 30 cadavers were studied to analyze the interconnections between FHL and FDL in the planta pedis, classify them in a modified classification system and measure distances to surgically relevant anatomic landmark. Results: The study revealed three primary types of interconnections. Type I, representing a proximal-to-distal connection from the FHL to the FDL, was observed in 85% of the feet. Type II, signifying a proximal-to-distal connection from the FDL to the FHL, was found in 11.66% of the feet. Type III, characterized by a crossed connection, was identified in 3.33% of the feet. The average point of branching for the FHL and FDL tendons was situated 4.5 cm and 3.5 cm distal to the navicular tuberosity, respectively. Conclusion: The presence of atypical proximal-to-distal interconnections from the FHL to the FDL may play a role in preserving residual function in the lesser toes following FDL transfer procedures. Awareness of anatomical variations in the location of these interconnections is crucial for preserving them during surgical interventions, ultimately mitigating the risk of functional impairment in the lateral toes post-tendon grafting.

This study aimed to compare the foot muscle morphology and foot posture between healthy adults and lifesavers in sandy beach sports. The participants included 15 lifesaver athletes and 15 healthy adults. Using a non-contact three-dimensional foot measurement device, the foot length, width, and arch height of the right foot were measured while standing and sitting without back support, and the transverse arch length ratio and arch height index were subsequently calculated. Muscle cross-sectional area was measured using an ultrasound imaging device. Muscle cross-sectional areas, arch height, foot width, arch height index, and transverse arch length ratio were larger in the lifesaver than in the healthy adult group. Lifesavers had higher arches and more developed intrinsic and extrinsic muscles than healthy adults. Performing physical activity while barefoot on sandy beaches may effectively develop the foot intrinsic and extrinsic muscles and raise the arch. [ABSTRACT FROM AUTHOR]

Background: Medial aspect of foot is unexplored due to its complex anatomy. Masterknot of Henry is an important landmark in this region, which plays a key role during tendon transfer procedures especially in those involving the flexor hallucis longus and flexor digitorum longus. We aim to determine the exact anatomical location of masterknot of Henry with respect to the bony prominences of the medial aspect of the foot and compare these measurements to the length of the foot. Methods: Twenty cadaveric below-knee specimens were dissected. Structures on the medial side of the foot were exposed. Distance of the masterknot of Henry from surrounding bony landmarks was measured. Depth of the masterknot from skin of the plantar aspect was also measured. Means of all parameters were calculated. Relation between measurements and the foot length was determined using correlation and regression analysis. P value of less than 0.05 was considered significant. Results: Distance of masterknot of Henry from navicular tuberosity was found to be fairly constant of 19.965 mm. Foot length was found to be correlating with the distance between masterknot of Henry and medial malleolus, navicular tuberosity and its depth from the skin. Conclusions: Navicular tuberosity can be considered an important surface landmark for the location of masterknot of Henry. Correlation of length of the feet with various measurements helps to find the masterknot considering the foot length to be an important variable. Good knowledge of surface anatomy leads to shorter operating time and less morbidity during procedures involving the flexor hallucis longus and flexor digitorum longus. [ABSTRACT FROM AUTHOR]

The Achilles is a commonly injured tendon, prone to degeneration and tear. Achilles tendon treatment ranges from conservative management to injections, tenotomy, open versus percutaneous tendon repair, graft reconstruction, and flexor hallucis longus transfer. Interpreting postoperative imaging of the Achilles tendon is a difficult task for many providers. This article clarifies these issues by presenting the imaging findings following standard treatments and depicts expected appearance versus recurrent tear and other complications. [ABSTRACT FROM AUTHOR]

El síndrome pospoliomielítico con déficit de la función del tendón tibial posterior puede presentarse con un pie equino flexible y marcha equina (steppage) en algunos pacientes. Se describe el caso de una paciente que solo conservaba la función muscular del tendón flexor hallucis longus y se decidió su transferencia al mediopié para obtener un pie plantígrado y restaurar la dorsiflexión.

Introduction. The Achilles tendon is one of the most frequently ruptured tendons in the human body. Surgical management commonly includes end to end repairs in acute tears, and chronic ruptures require autologous tendon transfer with Flexor hallucis longus or Flexor digitorum longus. Methods. A longitudinal observational study was done on 22 confirmed cases of chronic Achilles tendon rupture. Two incision technique of FHL tendon transfer with no exposure/debridement of the Tendoachilles was incorporated and functional outcome with American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, modified RUPP and Achilles Tendon Total Rupture (ATRS) scores both pre- and post-operatively were evaluated. Wound healing time and complications, heel-floor distance, calf circumference, hallux function and morbidity, graft characteristics and anatomic variation of master Knot of Henry were evaluated. Patients were followed up and assessed at 6 weeks, 3 months, and 6 months post-operatively. Results. The mean length of the FHL graft obtained from 2 incision technique was 8.09 cm. There was significant improvement in the Heel Rise Height Index from 7 to 63% (p < 0.0001), mean AOFAS ankle-hindfoot score from 43.9 to 89.6 (p < 0.001), mean ATRS Score from 19.6 to 79 (p < 0.0001) and mean Hallux MTP-IP scores to 96.3 (p < 0.0001) at 6th month follow up was found. 13 (59%) had "Excellent" modified RUPP scores. 20 (90.9%) had Type I variation while 2 (9.1%) had Type II variation in MKH. Mean length of the graft obtained was 8.09cm. Mean wound healing time was about 13 days and only one had wound complication. Conclusions. FHL tendon transfer has advantages of requiring minimal dissection, being stronger than FDL and PB and it is an in-phase transfer with the same axis of contraction. [ABSTRACT FROM AUTHOR]

The quadratus plantae (QP) is considered as a part of the plantar intrinsic foot muscles. This muscle has two lateral and medial heads of origin, both of which arise from the plantar surface of calcaneus, and insert into the tendon of flexor digitorum longus (FDL). Various functions have been attributed to the QP muscle, which includes assisting the plantar flexion of the lateral four toes, straightening the oblique pull of FDL and etc. Several anatomical variations of the QP muscle have been reported in the literature. During a routine dissection in the Department of Anatomy at Kerman University of Medical Sciences, a variant plantar muscle was observed in a 40-year-old male cadaver. In the present case, we report a rare variation associated with the insertion pattern of this muscle, which is reported for the first time in Iran. The tendinous end of the QP muscle was divided into three tendons and were then inserted to the inferior surface of 2nd, 3rd and 4th tendons of FDL. Also, a slim tendinous interconnection was also observed between the QP and flexor hallucis longus (FHL). The lack of connection between the FDL and FHL tendons was the other rare variation of this case. Exact knowledge of the possible variations of the QP muscle is of utmost importance to foot surgeons, clinicians and also anatomists. [ABSTRACT FROM AUTHOR]

Purpose: It was aimed to reveal whether the positions and dimensions of the extrinsic and intrinsic muscle tendons related to the hallux around the first metatarsal bone are affected by the severity of hallux valgus (HV) and whether tendon positional changes and tendon sizes affect each other. Methods: In formalin-fixed 46 feet, three HV angle subgroups (normal, mild, and moderate/severe) were defined. Width, thickness, and cross-sectional area (CSA) of tendons of the extensor hallucis longus (EHL) and brevis (EHB), abductor hallucis (AH), and flexor hallucis longus (FHL) were measured. On the clock model created in coronal plane, positional variations of each tendon were determined. Results: In the moderate/severe HV group, thickness and CSA of the EHB, width and CSA of the AH were smaller, compared to mild HV. Width and CSA of the FHL were smaller in moderate/severe HV than in the normal. Regardless of HV, the width and CSA of the FHL were greater in cases where the FHL was located more lateral, and the width of both FHL and AT were greater in cases where AH located was more plantar. Conclusion: The smaller tendon size of two intrinsic (one plantar and one dorsal) and one extrinsic muscle in the moderate/severe HV group indicates that changes in the tendons are evident in cases of high severity of HV but not in cases of mild HV. Accordingly, the changes do not appear to be due to a factor limited to only one aspect of the foot. It is recommended to consider the possible biomechanical effects of AH, FHL, and EHB tendon dimensional weakness in surgical planning in moderate/severe HV cases. [ABSTRACT FROM AUTHOR]

Background: Functional hallux limitus (FHLim) refers to a limitation of hallux dorsiflexion when the first metatarsal head is under load, whereas physiologic dorsiflexion is measured in the unloaded condition. Limited excursion of the flexor hallucis longus (FHL) in the retrotalar pulley has been identified as a possible cause of FHLim. A low-lying or bulky FHL muscle belly could be the cause of this limitation. However, to date, there are no published data regarding the association between clinical and anatomical findings. The purpose of this anatomical study is to correlate the presence of FHLim and objective morphologic findings through magnetic resonance imaging (MRI). Methods: Twenty-six patients (27 feet) were included in this observational study. They were divided into 2 groups, based on positive and negative Stretch Tests. In both groups, we measured on MRI the distance from the most inferior part of the FHL muscle belly and the retrotalar pulley as well as the cross-sectional area of the muscle belly 20, 30, and 40 mm proximal to the retrotalar pulley. Results: Eighteen patients had a positive Stretch Test and 9 patients had a negative Stretch Test. The mean distance between the most inferior part of the FHL muscle belly and the retrotalar pulley was 6.0 ± 6.4 mm for the positive group and 11.8 ± 9.4 mm for the negative group (P =.039). The mean cross section of the muscle measured at 20, 30, and 40 mm from the pulley were 190 ± 90, 300 ± 112, and 395 ± 123 mm2 for the positive group and 98 ± 44, 206 ± 72, and 294 ± 61mm2 for the negative group (P values.005,.019, and.017). Conclusion: Based on these findings, we can conclude that patients with FHLim do have a low-lying FHL muscle belly causing limited excursion in the retrotalar pulley. However, the mean volume of the muscle belly was comparable in both groups, and therefore bulkiness was not found to be a contributing factor. Level of Evidence: Level III, observational study. [ABSTRACT FROM AUTHOR]

Jogger's foot is characterised by a neuropathic pain along the medial arch of the foot caused by compression of the medial plantar nerve. It is more common in runners, especially when there is an anatomical predisposition or some extrinsic factor that may exert compression on the nerve. This article presents the case of a 59-year-old man, who had pain and paraesthesia along the medial plantar arch of the left foot, lasting for several months. Despite having undergone some conservative treatments (plantar orthosis and physiotherapy) and minimal invasive procedures (cortico-anaesthetic injection and shockwave therapy) the symptoms persisted and amyotrophy of the abductor hallucis muscle became clinically evident. At this point, a magnetic resonance image was taken, showing compression of the medial plantar nerve at the intersection of the flexor hallucis longus and the flexor digitorum longus tendons. Ultrasound-guided treatment with pulsed radiofrequency of the medial plantar nerve was then proposed to try and modulate his chronic neuropathic pain. After the procedure, the patient reported immediate relief of the symptoms, which were maintained over 6 months of follow up after the procedure. This case report illustrates a rare and frequently misdiagnosed cause of midfoot pain and its management using electromagnetic modulation of peripheral nerves by pulsed radiofrequency. This seems to be an effective technique, with long-lasting results. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the outcomes and complications after posterior ankle arthroscopy for the treatment of posterior ankle impingement syndrome, in a local population with a single surgeon series. Two-portal posterior ankle or hindfoot arthroscopy is an alternative option to open surgery in cases of posterior ankle impingement, that showed similar results but with less morbidity and faster recovery. There has been increasing interest in minimally invasive surgical techniques. Indications include extra- and intra-articular conditions and range from bony, cartilaginous to soft tissue pathology. Posterior ankle arthroscopy has been shown to be a good option in cases that are refractory to a period of conservative therapy. Posterior ankle arthroscopy also has known complications of sural nerve damage laterally and neurovascular bundle injury medially and also a steep learning curve that has been studied in the context of os trigonum excision. There have been few or no studies on the local Singaporean population and this article seeks to describe the various indications, results, and complications in the local Singaporean population by a single surgeon. Levels of Evidence: Level IV: Case series [ABSTRACT FROM AUTHOR]

Fibroma of the Tendon Sheath (FTS) is a rare soft tissue tumor commonly found in upper extremities. Usually, the lesions occur in wrists and hands. There are only a few cases of fibroma of the tendon sheath arising from the lower extremities have been reported. This case report describes a rare presentation of painful FTS that arises from flexor hallucis longus at the plantar aspect of the forefoot in a middle age lady. To our knowledge there is only one similar case reported previously.

The checkrein deformity is characterized by flexion contracture of the interphalangeal joint and extension contracture of the metatarsophalangeal joint. It is a rare condition occurring after lower extremity trauma, especially a malleolar fracture. Little is known about the possible cause and therapeutic strategy. This unique case presents a 20-year-old male patient with a diagnosis of the checkrein deformity secondary to open reduction and internal fixation of a Lauge–Hansen pronation external rotation stage IV malleolar fracture. After performing a detailed physical examination, radiographic evaluation, and ultrasonography, open exploration was performed to remove the hardware and correct the deformity with sole tenolysis of the flexor hallucis longus (FHL). In the 4-month follow-up, no recurrence of the checkrein deformity was observed. This deformity was caused by FHL adhesion. Interosseous membrane injury and fibular fracture together with local hematomas increases the risk of FHL adhesion. Open exploration and tenolysis of the FHL are feasible options to correct the checkrein deformity.

(1) Background: The purpose of this retrospective case-control study was to determine the relationship between the control of toe movements by flexor hallucis longus (FHL) and flexor digitorum longus (FDL) muscles and the response to treatment with botulinum toxin (BoNT) in post-stroke patients with claw toe. (2) Methods: Subjects with stroke-related leg paralysis/spasticity and claw toes received multiple injections of BoNT (onabotulinumtoxin A) into the FHL or FDL muscles. We investigated the relationship between the mode of transmission of FHL and FDL muscle tension to each toe (MCT) and treatment outcome using the data of 53 patients who received 124 injections with clinically recorded treatment outcome. We also dissected the potential variables that could determine the treatment outcome. (3) Results: The effectiveness of BoNT treatment was significantly altered by FDL-MCT (OR = 0.400, 95% CI = 0.162–0.987, p = 0.047). Analysis of the response to the first BoNT injection showed an odds ratio of FDL-MCT of approximately 6.0 times (OR = 0.168, 95% CI = 0.033–0.857, p = 0.032). The more tibial the influence of the FDL muscle on each toe, the better the treatment outcome on the claw toe. (4) Conclusions: The anatomic relation between FDL muscle and each toe seems to affect the response to treatment with BoNT in post-stroke patients with claw toes. [ABSTRACT FROM AUTHOR]

Checkrein deformity (CD) is a dynamic deformity of the hallux characterized by flexion contracture of the interphalangeal (IF) joint and extension contracture of the metatarsophalangeal (MTP) joint, worsened by ankle dorsiflexion. It is due to post-traumatic or ischemic retraction of the long hallux flexor tendon (FHL) following soft tissue trauma, leg fractures, ankle fractures and, more rarely, calcaneal or talar fractures. Diagnosis is essentially clinical, associated with imaging, to rule out unrecognized causes and evaluate fracture healing process. Few cases are reported in literature without univocal treatment. Background and Objectives: To analyze clinical and functional outcomes in patients with CD treated with release and retro-malleolar Z-plasty lengthening of FHL tendon. Materials and Methods: Patients diagnosed with CD treated with retro-malleolar (at tarsal tunnel) Z-plasty lengthening of the FHL tendon between January 2016 and August 2020 were included. Clinical and functional outcomes were collected on admission and post-surgery and analysed retrospectively. Patients with a minimum follow-up of 18 months were included. Results: A total of 14 patients, with mean age of 37.4 years old, with CD diagnosis were included in the study. All patients were suffering from post-traumatic CD and the mean time from trauma to onset of deformity was of 7 months (range 1–12). At a mean follow-up of 31.8 months (range 18–48) we found a significant improvement (p < 0.05) in terms of pain relief (VAS), function (AOFAS score) and ROM of the IP and MTP hallux joints. No recurrence, loss of strength, nerve injury or tarsal tunnel syndrome were observed. No patient required revision surgery. Conclusions: In this case series the retro-malleolar FHL tendon Z-plasty proved to be a suitable option for CD correction, allowing a good clinical and functional recovery. [ABSTRACT FROM AUTHOR]

Background: Anatomy of flexor hallucis longus (FHL) is essential for the achievement of tendon transfer and several procedures performed in the foot and ankle. The aim of this study was to evaluate the anatomical knowledge of FHL including the type and location of musculotendinous junction (MTJ), tendinous interconnections (TIC) morphology, its location related to Master Knot of Henry (MKH), and the pattern of TIC distribution.Materials and Methods: One hundred and sixty-six legs from 52 embalmed and 31 soft cadavers were assessed. The medial (MB) and lateral (LB) bellies of FHL were identified and traced until the end of the most distal muscle fibre to determine the medial and lateral MTJs. MTJ was classified into four types based on the existence and length of MB and LB: type 1, long LB and shorter MB; type 2, equal length of both bellies; type 3, only LB and no MB; type 4, long MB and shorter LB. Low lying muscle belly was defined as muscle extending beyond the zero point (the point of intersection between distal osseous part of tibia and FHL tendon). The distance between MTJ and zero point was measured. TIC was classified into seven types based on the direction and number of slip: type I, one slip from FHL to flexor digitorum longus (FDL); type II, crossed connection: type III, one slip from FDL to FHL; type IV, no connection; type V, two slip from FHL to FDL; type VI, two slip from FHL to FDL and one slip from FDL to FHL; type VII, two slips from FDL to FHL and one slip from FHL to FDL. The distance between the TIC and MKH was measured. TIC distribution was defined into four types based on slip distribution to lesser toes: type a, distributed to second toe; type b, distributed to second and third toes; type c, distributed to second to fourth toes, and type d, distributed to second to fifth toes.Results: Type 1 and type 3 of MTJ morphology were found in 87.3% and 12.7%, respectively. Low lying LB was detected in 66.13% of cases with a mean distance of 13.10 ± 4.51 mm. All MBs ended proximal to the zero point with a mean distance of -21.99 ± 13.21 mm. Three types of TIC (I, II, V) were identified. The highest frequency was type I (82.93%). In addition, a new type of TIC was depicted in 8.53% of cases. Part of the FHL tendon in this type fused with FDL tendon and the rest extended directly to the first toe. TIC could be located either proximal, distal or at the MKH. The highest prevalence was distal to MKH in 51.67% of cases with a mean distance of 11.23 ± 5.13 mm and 8.73 ± 4.2 mm in low lying and non-low-lying groups, respectively. Four types of slip distribution to lesser toes were defined, mostly in type b. No statistically significant differences were detected among all parameters including genders, sides, and groups.Conclusions: Knowledge of this investigation might enhance the clinical efficacy of tendon harvesting and transfer in foot and ankle surgery. [ABSTRACT FROM AUTHOR]

Background/Purpose: To investigate the relationship between anatomical variation of the toe flexor muscles and the resulting variation of toe flexion angle from tendon excursion. Methods: Six cadaveric lower extremities preserved by Thiel's embalming method were evaluated. The toe flexor muscles were distracted individually and toe flexion angles measured. The anatomic variation were observed by gross anatomical dissection. Results: The toes with tendinous slips of flexor hallucis longus (FHL) showed similar flexion angles between the FHL and flexor digitorum longus. However, there were differences observed regarding toe flexion and tendon excursion of the flexor digitorum muscle and quadratus plantae due to the anatomic variations. Conclusion: The anatomical variation of the toe flexor muscles should be taken into account when evaluating toe function and applying exercise therapy for foot disorders. [ABSTRACT FROM AUTHOR]

A novel combination of variations involving the quadratus plantae muscle (QP) and its relationship to the flexor hallucis longus (FHL) tendon was observed unilaterally in the right foot of an 88-year-old female cadaver during routine dissection. The medial head of QP was observed inserting onto the tendon of FHL rather than the tendon of flexor digitorum longus (FDL), while also contributing to an anomalous tendinous slip to the second digit in conjunction with the tendon of FHL. The tendon of FHL also gave off a slip to the third digit. Both tendinous slips attached distally to the digital tendons of FDL. Lastly, the lateral head of QP inserted onto the tendinous slip from FHL to the third digit. Ninety-five additional feet were assessed for these variations, but none were observed. This combination of variations expands upon the proposed actions of QP in the literature. Furthermore, connections between the tendons of the midfoot are of clinical significance for harvesting tendon grafts. [ABSTRACT FROM AUTHOR]

Long-term friction of the FHL tendon's sheath (caused by sporting activities) can result in tendinitis, which causes pain in the foot and ankle and consequently interferes with everyday life and foot function. The FHL tendon is crucial for maintaining foot stability and can be damaged by overuse. FHL tendinitis can be also caused by inflammatory tendon sheath filled. Arthroscopy can play a role in the diagnosis and treatment of this condition. A 28-year-old female with left ankle pain was brought to our clinic after slipping on a train platform nine months ago. X-rays and MR imaging revealed a complete tear of the ATFL, minimal joint effusion, and a bony protrusion causing impingement. Arthroscopic surgery was performed, and the patient's pain sensation improved to 0–1 in the visual analogue scale (VAS) within three weeks. The Foot and Ankle Ability Measure (FAAM) score increased from 8 % to 100 %, and the patient was able to walk and perform daily activities normally. The FHL tendon sheath begins at the posterior tubercles of the talus and forms a fibroosseous tunnel along the medial calcaneus, potentially leading to impingement during ankle or hallux dorsiflexion. FHL tendon impingement and tendinitis share clinical manifestations, and if conservative treatments (NSAIDs, physical therapy) fail after 6 months, arthroscopic surgery is recommended for its minimally invasive benefits. Both arthroscopic and open surgical techniques yield positive outcomes for FHL pathologies; however, they carry risks such as neurovascular complications, highlighting the necessity for surgical precision and expertise. We concluded that in this case, FHL impingement was caused by the bony protrusion from Stieda process fragment. It was demonstrated that the arthroscopic surgery with loose body removal was successful and practical. • The Flexor Hallucis Longus (FHL) muscle originates from the interosseous membrane and the fibula, extending down to the great toe. • Overuse of the FHL tendon can lead to tendinitis, resulting in pain and reduced foot function. • FHL impingement syndrome is characterized by the muscle belly being too long, impacting the tendon sheath at the talus. • In cases where conservative methods have failed, surgical intervention has been associated with positive outcomes, notably the resolution of pain andnormal toe and ankle joint mobility, and a return to pre-injury levels of activity. • This case showed an FHL impingement caused by a bony protrusion from the Stieda process fragment, and arthroscopic surgery with removal of this loose body was effective in alleviating the patient's symptoms. [ABSTRACT FROM AUTHOR]

Fibroma of the Tendon Sheath (FTS) is a rare soft tissue tumor commonly found in upper extremities. Usually, the lesions occur in wrists and hands. There are only a few cases of fibroma of the tendon sheath arising from the lower extremities have been reported. This case report describes a rare presentation of painful FTS that arises from flexor hallucis longus at the plantar aspect of the forefoot in a middle age lady. To our knowledge there is only one similar case reported previously. [ABSTRACT FROM AUTHOR]

Purpose: The aims of this review were to form a more precise description for Master Knot of Henry (MKH), and to modify classifications related to interconnections between flexor hallucis longus (FHL) and flexor digitorum longus (FDL) for showing all configurations in the literature. Methods: A literature search was performed in main databases to obtain information related to anatomical definitions and variations of MKH. The search was carried out using the following keywords: "Master Knot of Henry", "Chiasma plantare", "Flexor hallucis longus" and "Flexor digitorum longus". Information extracted from the studies was: sample size, numerical values, classifications, variation types, incidence of types, anatomical definitions of MKH, year of publication, and type of study. Results: This study proposes that MKH should be defined as the intersection territory where FDL crosses over FHL in the plantar foot. The postchiasmatic plantar area located at distal to MKH (the narrow space between MKH and the division of FDL) should be termed as the triangle of Henry. Moreover, the classification systems showing different configurations related to interconnections situated at Henry's triangle were updated as eight types to present all forms in the literature. Conclusion: Our definitions may assist in determining the precise anatomical boundaries of MKH, and thus facilitate the use of MKH as a surgical landmark. In addition, our modified classification systems covering all variations in the current literature may be helpful for surgeons and anatomists to understand formations of the triangle of Henry, and the long flexor tendons of the lesser toes. [ABSTRACT FROM AUTHOR]

Background: A common challenge in flatfoot reconstruction arises when there are multiple locations of collapse within the medial column. An extension of arthrodesis may lead to complications such as stiffness or adjacent joint arthritis. The purpose of this study was to report outcomes of flatfoot reconstruction using the dynamic medial column stabilization (DMCS) technique, which transfers the flexor hallucis longus (FHL) tendon to the first metatarsal base to support the entire medial column.Methods: We retrospectively reviewed 14 consecutive patients (14 feet) who underwent DMCS as an adjunct to flatfoot reconstruction. In all cases, a medial displacement calcaneal osteotomy and gastrocnemius recession were performed to address hindfoot valgus deformity and heel cord tightness, respectively. Deformity correction was assessed using preoperative and postoperative weightbearing radiographs. The newly defined metatarsal-cuneiform articular angle (MCAA) and naviculo-cuneiform articular angle (NCAA) were measured to assess correction at each medial column joints. Clinical outcomes included the FFI and VAS scores. Any complications related to the surgery were investigated.Results: All radiographic parameters significantly improved postoperatively. The sagittal plane correction occurred at all three joints within the medial column. Clinically, both FFI and VAS improved significantly at the final follow-up. One patient developed plantar pain under the first metatarsal head that may have been associated with the overtightening of the transferred tendon.Conclusion: DMCS using FHL tendon transfer to the first metatarsal base was a useful technique for restoring the medial arch and correcting three planar deformities in the setting of flatfoot deformity. [ABSTRACT FROM AUTHOR]