Blood supply of the flexor hallucis longus tendon with regard to dancer's tendinitis: injection and immunohistochemical studies of cadaver tendons

Novel presentation of rigid flat foot flexor hallucis longus passing through the subtalar joint: A comprehensive case report

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.

Anatomical evaluations of the adipose tissue surrounding the flexor hallucis longus tendon

This study aimed to evaluate the presence of adipose tissue surrounding the flexor hallucis longus (FHL) tendon through gross dissection and magnetic resonance imaging (MRI). Grossly, we observed the FHL tendon and surrounding tissues in nine cadavers. Using MRI, we quantitatively evaluated each tissue from the horizontal plane in 40 healthy ankles. Macroscopic autopsy revealed the presence of adipose tissue behind the ankle joint between the FHL and fibula, and horizontal cross-sections showed an oval-shaped adipose tissue surrounding the tendon. The cross-sectional area on MRI was 14.4 mm2 (11.7-16.7) for the FHL tendon and 120.5 mm2 (100.3-149.4) for the adipose tissue. Additionally, the volume of the adipose tissue was 963.3 mm3 (896.2-1115.6). There is an adipose tissue around FHL tendon and maybe this close anatomical relationship might influence the function of the tendon and be involved in its pathologies.

Effect of Aging on Tendon Biology, Biomechanics and Implications for Treatment Approaches

Tendon aging is associated with an increasing prevalence of tendon injuries and/or chronic tendon diseases, such as tendinopathy, which affects approximately 25% of the adult population. Aged tendons are often characterized by a reduction in the number and functionality of tendon stem/progenitor cells (TSPCs), fragmented or disorganized collagen bundles, and an increased deposition of glycosaminoglycans (GAGs), leading to pain, inflammation, and impaired mobility. Although the exact pathology is unknown, overuse and microtrauma from aging are thought to be major causative factors. Due to the hypovascular and hypocellular nature of the tendon microenvironment, healing of aged tendons and related injuries is difficult using current pain/inflammation and surgical management techniques. Therefore, there is a need for novel therapies, specifically cellular therapy such as cell rejuvenation, due to the decreased regenerative capacity during aging. To augment the therapeutic strategies for treating tendon-aging-associated diseases and injuries, a comprehensive understanding of tendon aging pathology is needed. This review summarizes age-related tendon changes, including cell behaviors, extracellular matrix (ECM) composition, biomechanical properties and healing capacity. Additionally, the impact of conventional treatments (diet, exercise, and surgery) is discussed, and recent advanced strategies (cell rejuvenation) are highlighted to address aged tendon healing. This review underscores the molecular and cellular linkages between aged tendon biomechanical properties and the healing response, and provides an overview of current and novel strategies for treating aged tendons. Understanding the underlying rationale for future basic and translational studies of tendon aging is crucial to the development of advanced therapeutics for tendon regeneration.

Posterior Ankle Arthroscopy for Flexor Hallucis Longus Entrapment: A Case Report

Introduction:

Stenosing tenosynovitis is a chronic disorder frequently observed in finger triggering of a digit. Regarding the toes, although entrapment of the flexor hallucis longus (FHL) has already been reported in a few cases among sports players, the clinical condition is uncommon. Besides, the case without any specific causes is particularly rare.

Case Report:

We report the case of a 26-year-old male with FHL entrapment. Even though he was unaware of any cause, he felt tenderness on the posteromedial side of his left ankle, and his great toe was locked in the flex position. Magnetic resonance imaging indicated effusion in the tendon sheath of the FHL and the possibility of a partial tear of the FHL. We hypothesized that the scar tissue secondary to the partial tear of the FHL may have been irritated at the retrotalar pulley below the sustentaculum tali, where the FHL glides. Therefore, posterior ankle arthroscopy was performed for the treatment of the FHL entrapment.

Conclusion:

Orthopedic surgeons should list this pathology as a differential diagnosis of posterior ankle pain, even in non-athletes.

Ultrashort echo time (UTE) imaging reveals a shift in bound water that is sensitive to sub-clinical tendinopathy in older adults

OBJECTIVE

Use ultrashort echo time (UTE) magnetic resonance imaging to quantify bound water components of asymptomatic older Achilles tendons and investigate the relationship between UTE findings and imaging assessment of sub-clinical tendinopathy.

MATERIALS AND METHODS

Thirteen young (age 25 ± 4.8) and thirteen older (age 67 ± 4.7) adults were tested. A UTE sequence was used to quantify the transverse relaxation times of bound ([Formula: see text]) and free ([Formula: see text]) water and the bound water fraction (F_s) in the Achilles tendon. Anatomical images were collected and graded by a musculoskeletal radiologist to identify signs of sub-clinical tendinopathy. Two-sample t tests were used to compare [Formula: see text], [Formula: see text], and F_s between age groups and between adults with and without sub-clinical tendinopathy.

RESULTS

Older tendons exhibited a 60% longer [Formula: see text] (p = 0.004), similar [Formula: see text] (p = 0.86), and 5% smaller F_s (p = 0.048) than young tendons. Seven older adult tendons exhibited tendon thickening and increased signal intensity indicative of sub-clinical tendinopathy. This subset of tendons exhibited a 7% smaller bound water fraction (p = 0.02) and significantly longer [Formula: see text] (p < 0.001) than the normal tendons from young and older adults.

CONCLUSION

Older adult tendons exhibited unique UTE signatures that are consistent with disruption of the collagen fiber network and changes in macromolecular content. UTE imaging metrics were sensitive to early indicators of tissue degeneration identified on anatomical images and hence could provide a quantitative biomarker by which to track changes in tissue health resulting from injury, disease, and treatment.

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.

Reconstruction of Neglected Flexor Hallucis Longus Tendon Rupture: A Case Report

Isolated rupture of the flexor hallucis longus tendon is an unusual injury. We present the case of a neglected flexor hallucis longus tendon closed traumatic rupture at the plantar aspect of the first phalangeal head of the great toe in a middle-age male. The injury occurred while he was dancing. Because end-to-end tendon suture was impossible, the ensuing gap was repaired using a free plantaris tendon graft. We present the operative repair benefit of the flexor hallucis longus tendon rupture to regain the function and strength of the interphalangeal joint of the hallux, avoid extension of the distal phalanx, and maintain the longitudinal arch of the foot.

The Arterial Anatomy of the Lateral Ligament Complex of the Ankle: A Cadaveric Study

BACKGROUND

Ankle sprains are the most common musculoskeletal injury in the United States. Chronic lateral ankle instability can ultimately require operative intervention to decrease pain and restore stability to the ankle joint. There are no anatomic studies investigating the vascular supply to the lateral ankle ligamentous complex.

PURPOSE

To define the vascular anatomy of the lateral ligament complex of the ankle.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Thirty pairs of cadaveric specimens (60 total legs) were amputated below the knee. India ink, followed by Ward blue latex, was injected into the peroneal, anterior tibial, and posterior tibial arteries to identify the vascular supply of the lateral ligaments of the ankle. Chemical debridement was performed with 8.0% sodium hypochlorite to remove the soft tissues, leaving casts of the vascular anatomy intact. The vascular supply to the lateral ligament complex was then evaluated and recorded.

RESULTS

The vascular supply to the lateral ankle ligaments was characterized in 56 specimens: 52 (92.9%) had arterial supply with an origin from the perforating anterior branch of the peroneal artery; 51 (91.1%), from the posterior branch of the peroneal artery; 29 (51.8%), from the lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), from the posterior tibial artery. The anterior branch of the peroneal artery was the dominant vascular supply in 39 specimens (69.6%).

CONCLUSION

There are 4 separate sources of extraosseous blood supply to the lateral ligaments of the ankle. In all specimens, the anterior talofibular ligament was supplied by the anterior branch of the peroneal artery and/or the lateral tarsal artery of the dorsalis pedis, while the posterior talofibular ligament was supplied by the posterior branch of the peroneal artery and/or the posterior tibial artery. The calcaneofibular ligament received variable contributions from the anterior and posterior branches of the peroneal artery, with few specimens receiving a contribution from the lateral tarsal or posterior tibial arteries.

CLINICAL RELEVANCE

Understanding the vascular anatomy of the lateral ligament complex is beneficial when considering surgical management and may provide insight into factors that lead to chronic instability.

The Arterial Anatomy of the Deltoid Ligament: A Cadaveric Study

BACKGROUND

There is an increasing interest in the operative treatment of deltoid ligament disruption in the setting of chronic ankle instability. Understanding the vascular anatomy of the deltoid complex is beneficial when considering operative procedures on the medial ankle and may provide insight into factors that lead to chronic deltoid insufficiency and ankle instability.

METHODS

Thirty-two pairs of cadaveric specimens (64 total legs) were amputated below the knee, and the tibialis anterior, tibialis posterior, and peroneal arteries were injected with India ink and Ward's blue latex. Specimens then underwent chemical debridement to identify the vascular supply to the deltoid ligament. A subset of specimens also underwent intraosseous debridement using the modified Spalteholz technique.

RESULTS

The vascular supply to the deltoid ligament was clearly visualized in 60 (93.8%) specimens. Fifty-eight specimens (96.7%) had arterial supply with an origin from the medial tarsal artery, 57 specimens (95%) had supply from the tibialis posterior artery, and 23 (38.3%) specimens had supply from the tibialis anterior artery. All specimens had at least 1 location of intraosseous vascular supply, either at the medial malleolus or medial talus.

CONCLUSION

There were 3 separate extraosseous sources and 2 intraosseous sources of vascular supply to the deltoid ligament.

CLINICAL RELEVANCE

Knowledge of the vascular supply may aid in identifying factors that predispose a subset of patients with medial ankle sprains to failure of conservative treatment, as well as provide useful anatomic information when considering operative treatment for chronic ankle instability.

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

Hindfoot endoscopy for posterior ankle impingement syndrome and flexor hallucis longus tendon disorders

Hindfoot endoscopic surgery is an alternative to conventional open surgery for treatment of posterior ankle pain. This procedure can be applied not only for accurate diagnosis under direct visualization but also for low-invasive therapy. Common indications for hindfoot endoscopy are posterior ankle impingement syndrome and damaged soft tissue. Several studies have reported good clinical outcomes of hindfoot endoscopy with lower complication rates than in the conventional open procedure. Nerve injury remains a common complication. To avoid such injury, make a posterolateral portal just lateral to the Achilles tendon and perform the hindfoot endoscopic procedure in the region lateral to the flexor hallucis longus tendon.

Posterior hindfoot arthroscopy: a review

In recent years, minimally invasive surgery has developed and progressed the standard of care in orthopaedics and sports medicine. In particular, the use of posterior hindfoot arthroscopy in the treatment of posterior ankle and hindfoot injury is increasing rapidly as a means of reducing pain, infection rates, and blood loss postoperatively compared with traditional open procedures. In athletes, hindfoot arthroscopy has been used effectively in expediting rehabilitation and ultimately in minimizing the time lost from competition at previous levels. Van Dijk et al were the first to describe the original 2-portal technique, which remains the most commonly used by surgeons today and forms the basis for this review. The current evidence in the literature supports the use of 2-portal hindfoot arthroscopy as a safe, primary treatment strategy for symptoms of posterior ankle impingement, including resection of os trigonum, treatment of flexor hallucis longus and peroneal tendon injury, treatment of osteochondral lesions of the ankle, and the resection of subtalar coalitions. In this review, we present where possible an evidence-based literature review on the arthroscopic treatment of posterior ankle and hindfoot abnormalities. Causes, diagnosis, surgical technique, outcomes, and complications are each discussed in turn.

Effect of angiogenesis-related cytokines on rotator cuff disease: the search for sensitive biomarkers of early tendon degeneration

BACKGROUND

Hallmarks of the pathogenesis of rotator cuff disease (RCD) include an abnormal immune response, angiogenesis, and altered variables of vascularity. Degenerative changes enhance production of pro-inflammatory, anti-inflammatory, and vascular angiogenesis-related cytokines (ARC) that play a pivotal role in the immune response to arthroscopic surgery and participate in the pathogenesis of RCD. The purpose of this study was to evaluate the ARC profile, ie, interleukin (IL): IL-1β, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and angiogenin (ANG), in human peripheral blood serum and correlate this with early degenerative changes in patients with RCD.

METHODS

Blood specimens were obtained from 200 patients with RCD and 200 patients seen in the orthopedic clinic for nonrotator cuff disorders. Angiogenesis imaging assays was performed using power Doppler ultrasound to evaluate variables of vascularity in the rotator cuff tendons. Expression of ARC was measured by commercial Bio-Plex Precision Pro Human Cytokine Assays.

RESULTS

Baseline concentrations of IL-1β, IL-8, and VEGF was significantly higher in RCD patients than in controls. Significantly higher serum VEGF levels were found in 85% of patients with RCD, and correlated with advanced stage of disease (r = 0.75; P < 0.0005), average microvascular density (r = 0.68, P < 0.005), and visual analog score (r = 0.75, P < 0.0002) in RCD patients. ANG and IL-10 levels were significantly lower in RCD patients versus controls. IL-1β and ANG levels were significantly correlated with degenerative tendon grade in RCD patients. No difference in IL-6 and bFGF levels was observed between RCD patients and controls. Patients with degenerative changes had markedly lower ANG levels compared with controls. Power Doppler ultrasound showed high blood vessel density in patients with tendon rupture.

CONCLUSION

The pathogenesis of RCD is associated with an imbalance between pro-inflammatory, anti-inflammatory, and vascular ARC.

Injury patterns in female Irish dancers

OBJECTIVE

To determine the type of Irish dance injuries requiring evaluation and treatment by a sports medicine physician.

DESIGN

Cross-sectional retrospective chart review.

SETTING

Academic sports medicine center in the Midwest.

PARTICIPANTS

Female Irish dancers who presented at an academic sports medicine center from June 2002 to September 2009.

MAIN OUTCOME MEASURES

This was a retrospective chart review identifying injuries sustained to female Irish dancers in a single Irish dance company in a major metropolitan area. Dancers were evaluated and injuries were diagnosed by one sports medicine physician at an academic sports medicine center.

RESULTS

Sixty-nine female Irish dancers, ages 8 to 23 years, sustained 217 recorded injuries. The top injuries included stress fractures (29.9%), patellofemoral pain syndrome (11.1%), Sever condition (6.0%), ankle sprains (5.1%), posterior tibialis tendonitis (4.6%), and plantar fasciitis (4.6%). The most common site for stress fractures were the sesamoids, comprising 27.7% of all stress fractures and 8.3% of total injuries. The majority of injuries were in the lower extremities (94.9%), remaining injuries involved the lumbosacral spine and pelvis (5.1%). Most dancers (79.7%) had multiple injuries. The number of injuries per dancer increased as the dancer's level increased. There was a trend for the average age of the dancers to decrease as the level of skill increased.

CONCLUSION

Lower extremity injuries comprised the majority of Irish dance injuries. Stress fractures (29.9%), patellofemoral pain syndrome (11.1%), and Sever condition (6.0%) were the most common injuries.

[Tenocytes and the extracellular matrix : a reciprocal relationship]

The characteristic cells in tendons and ligaments are called tenocytes, which are responsible for the formation and turnover of the extracellular matrix. They react to external stimuli and facilitate the functional adaptation of the proteoglycan and collagen network to mechanical requirements. Via numerous cellular processes they form a complex communicating network which demonstrates coordinated directional reactions. As is common to all tissues in the human body, tendons are subject to age changes which influence the tenocytes, but additionally the structural organization and hence the function of the extracellular matrix. The function and organization of tendons are also affected by mechanical forces, as well as by various cytokines produced in the tissue and by the application of anti-inflammatory medication.

One-stage treatment of deep infection following repair of Achilles tendon rupture with flexor hallucis longus transfer

We present one-stage treatment of deep infection following repair of Achilles tendon rupture using flexor hallucis longus transfer. Flexor hallucis longus was used not only to connect the defect in Achillles tendon, but also to control the soft tissue infection with its abundant blood supply, simultaneously. The clinical results for the two patients in this report were excellent without major complication.

Structure-function relationships in tendons: a review

The purpose of the current review is to highlight the structure-function relationship of tendons and related structures to provide an overview for readers whose interest in tendons needs to be underpinned by anatomy. Because of the availability of several recent reviews on tendon development and entheses, the focus of the current work is primarily directed towards what can best be described as the 'tendon proper' or the 'mid-substance' of tendons. The review covers all levels of tendon structure from the molecular to the gross and deals both with the extracellular matrix and with tendon cells. The latter are often called 'tenocytes' and are increasingly recognized as a defined cell population that is functionally and phenotypically distinct from other fibroblast-like cells. This is illustrated by their response to different types of mechanical stress. However, it is not only tendon cells, but tendons as a whole that exhibit distinct structure-function relationships geared to the changing mechanical stresses to which they are subject. This aspect of tendon biology is considered in some detail. Attention is briefly directed to the blood and nerve supply of tendons, for this is an important issue that relates to the intrinsic healing capacity of tendons. Structures closely related to tendons (joint capsules, tendon sheaths, pulleys, retinacula, fat pads and bursae) are also covered and the concept of a 'supertendon' is introduced to describe a collection of tendons in which the function of the whole complex exceeds that of its individual members. Finally, attention is drawn to the important relationship between tendons and fascia, highlighted by Wood Jones in his concept of an 'ectoskeleton' over half a century ago - work that is often forgotten today.

Dance-Related Injury

Although dance medicine has derived extensive knowledge from sports medicine, some aspects covered in the practice of dance medicine are unique to this field. Acute and overuse injuries must be analyzed within the scope of associated mechanisms of injury, mainly related to the practice of specific dance techniques. Even though most available medical literature concerning dance medicine is specific to ballet-related conditions, many of the concepts covered here and in other articles can be helpful in the treatment and diagnosis of participants in other dance disciplines. Continued research is expanding the knowledge on injury patterns of different dance disciplines. It is the experience of dance practitioners that dancers are quite in touch with their bodies; thus, when their ailments are systematically analyzed, and underlying cause can usually be identified. In this sense, it is evident that the principles of dance medicine and rehabilitation allow the practitioner to arrive at a diagnosis and treat the underlying causes to prevent reinjury, ameliorate sequelae from injury, and minimize residual deficits after injury.