Flexor Hallucis Longus Tendinopathy

Often called “dancers tendonitis” due to its prevalence in classical ballet dancers, FHL tendinopathy actually happens to various athletes whose sports require repetitive push-off and extreme plantar flexion (pointing of the foot), such as sprinters, soccer players, gymnasts, and even swimmers.  

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The Flexor Hallucis Longus (FHL) muscle is located in the back of the lower leg, originating from the fibula and traveling behind the Achilles tendon. The FHL tendon then passes the inside of the ankle through the tarsal tunnel, and travels along the instep of the foot, ending at the big toe. Its function is to flex the hallux - or big toe. It also has an important role in controlling mid-foot pronation and supination.

Because of these roles, the FHL functions as a powerful convertor of force from the rear foot to the big toe. However, repetitive pushing off the foot and toes can sometimes lead to irritation. This can be worsened when combined with eversion - or an outward motion of the toes relative to the ankle. Often, young dancers will evert when attempting to achieve greater “turnout”, but this also can be seen in runners as excessive pronation - or “arch collapsing” - most often due to strength deficits in the stabilizers of the limb.

If you’ve irritated this muscle-tendon unit, you may experience pain within the foot or at the back of the ankle depending where along the tendon inflammation has occurred. Some may also experience the big toe “getting stuck” with active movement, or swelling and a crunchy-sensation along the inside of the ankle. Flexing the big toe against resistance, or forcing the foot into a pointed position may also be painful.

While the exact physical cause of FHL injury is under debate, it is believed that the tendon can snag either at the ankle in the tarsal tunnel,  in the mid-foot, or at the sesamoids (two teeny round accessory bones) of the big toe. When combined with repetitive motion, this entrapment of the tendon creates micro-trauma. If left untreated, this can lead to tissue damage. The body's inflammatory response begins to heal these micro-tears, sending more blood and nutrients to the area. This inflammation of the tendon is what is called tendinopathy. 

Restriction of the FHL routinely occurs in three spots:

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• Tarsal Tunnel at inside of ankle, star.

• Intersection of FHL with neighboring Flexor Digitorum Longus tendon, triangle.

• Attachment of FHL to the first bone (proximal phalange) of the big toe, square.

To learn more, check out these articles and texts:

1. https://www.sportsmedtoday.com/fhl-tendinopathy-va-132.htm

2. Quirk R. Common foot and ankle injuries in dance. Orthop Clin North Am. 1994 Jan;25(1):123-33.

3. Pagenstert GI, Victor V, Hintermann B. Tendon injuries of the foot and ankle in athletes. Clin Ortho Trauma. 2004; 52(1):11-21.

4. Simpson M, Howard T. Tendinopathies of the foot and ankle. Am Fam Physician. 2009 Nov 15;80(10):1107-1114.

5. https://www.sportsinjurybulletin.com/the-flexor-hallucis-longus/#:~:text=Overuse%20conditions%20in%20the%20FHL,posterior%20or%20postero%2Dmedial%20ankle.

6. Bone Joint Surg. 78A:1491-1500, 1996

7. Am J Sports Med. 1977;5:84-88

8. J Orthop Sports Phys 1983; 5: 204-206

9. Norris R. Common Foot and Ankle Injuries in Dancers. In: Solomon R, Solomon J, Minton S, eds. Preventing Dance Injuries. 2nd ed. Champaign, Ill: Human Kinetics; 2005: 39-51

10. Foot Ankle Int. 2005; 26: 291-303

Back At It

To wrap up our section on lumbar disc injury, Nina and I break down some of the most common patient questions we receive. As an AT, Nina is accustom to triaging athletes in pain, helping them find confidence in their plan of care.

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SV: For the past month, we’ve been sharing the latest research on lumbar disc pathologies. As a recap, what are your top three take aways for experiencing back pain?

NS: We’ve covered a ton of information on this topic recently, looking at the impact of pregnancy as well as injury. The overall takeaway is that each individual’s experience can be different- this goes for symptoms and solutions. That’s why personalized care can have such a big impact for back pain. Similarly, there isn’t one guaranteed strategy for managing a lumbar disc injury. A combination of treatments, including soft tissue work, stability and mobility exercises, and pain management, is typically needed. Last, use this as an opportunity. For most people, an injury like a disc herniation can be a catalyst to make adjustments to their behaviors, allowing them to emerge stronger than before.

SV:  How does this differ from the type of back pain caused by pulling a muscle?

NS: Discogenic pain has a different quality; many patients report feeling sharp, electric sensations, while others complain of weakness. Nerve pain can “travel,” sending irritation down one or both legs. Muscle spasm often accompanies a disc injury- it’s a protective strategy. Muscles of the back will automatically tighten above and below the injured disc to limit movement. This tightening makes it difficult to use muscle systems, or groups of muscles designed to support compound movements, effectively.

Pulling a muscle, or overusing a muscle, can usually be correlated with a specific action or activity. You may feel tight, or restricted. This should resolve, or feel considerably better, in 72 hours if it’s just muscular.

SV: Here’s a popular combo question- do patients need to get imaging for this type of injury? How likely will they need surgery?

NS: It’s a valid question- too often, we only hear about worst case scenarios for injuries. Unless you’ve suffered a traumatic injury, like a car crash, we don’t typically recommend imaging right away. Rehab exercises and pain management will be the most productive first steps. If you eventually need surgery down the road, being as strong as possible going in will dramatically help your recovery!

Surgery makes the most sense for patients who have a high risk of complications- like if your herniation or displacement is so severe you may cause permanent damage to your spinal column- or for those who haven’t succeeded with conservative care after a number of months.

We’re big believers that patients should be the center of their plan of care, with a variety of clinicians and specialists, coaches and supporters surrounding them. Without a different perspectives, you can overlook options. Ask questions, get second options- be your best advocate!

SV: Once someone injures their back, does that mean they can never workout or play sports again?

NS: In the vast majority of cases, definitely not! Most patients are able to return fully to their previous level of activity. Like any major injury, it will take dedication and focus to recover. It’s essential to allow your body enough time to heal, and to correctly learn, or re-learn, movement patterns. Look for rehab practitioners that understand the demands of your activity, and can help get you there. Stopping at 65-75% better increases your chance of re-injury significantly.

SV: With back pain being one of the most prevalent injuries, how can someone lower their risk for injury?

NS: Regular physical activity will help to protect against a number of ailments and injuries. Particularly with the recent transition to virtual learning and working, movement is even more important, as we are naturally more sedentary in this scenario. Adding in tri-planar exercise, including linear, lateral and rotational work, can help make sure you’re prepared for whatever life throws you! If you’re new to exercise, or struggling with home exercise routines, setting up an appointment to work with a clinician or coach can give you the confidence you need to move safely.

SV: At Physical TheraPT, as many of our patients know, we love staying current on the latest innovations in exercise and rehab equipment. What’s your favorite product out there right now for back pain patients?

NS: For patients still in the early stages of recovery, I really like the biofeedback cuff. This deconstructed blood pressure cuff helps increase awareness of pelvic stability and highlights how well someone is able to maintain a braced position when you add on movement. For those who are out of pain, and show progress with more challenging exercises, the 3D strap is my favorite. Don’t be deceived by the simple nature of this piece of equipment! It adds rotational load to almost any movement pattern, allowing athletes to adapt and practice in a safe environment.

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SV: Last question- what’s your go-to strategy for pain relief with this type of injury?

NS: Finding a position of comfort that you can rest in. Back injuries can feel unrelenting- having a position that gives you some relief is critical in the beginning stages of recovery. Laying on a firm surface, resting on your back with knees bent and feet planted, referred to as Hook-Lying Position, is generally safe for most patients. Others may find relief with a bit of light traction, leaning into your elbows at a counter, or floating in a pool.

Consistent Advice for Inconsistent Times

Seemingly almost every day, this year has thrown unprecedented challenges our way. As a country, and as a community, it can feel like we simply can’t catch a break. This air of overwhelming chaos and danger can trigger feelings of distress and distraction, and impact our normal immune response, throughout coping strategies like emotional eating or alcohol consumption, or poor quality sleep. Good news, these feelings and responses are very normal. Bad news, these behaviors are correlated with an increased risk of injury.

“I don’t know if I can do this”

As athletes and performers, we each possess a deep spirit of resilience. Resilience is defined by the American Psychological Association as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.” Each tryout, audition, tie breaker, performance and championship game has reinforced that spirit. We have each gone through challenge, and emerged stronger.

Brené Brown reminds us in her 2015 book, Rising Strong, that resilient leaders all show three key attributes:

First, they recognize the central role that relationships and story play in culture and strategy, and they stay curious about their own emotions, thoughts, and behaviors. Second, they understand and stay curious about how emotions, thoughts, and behaviors are connected in the people they lead, and how those factors affect relationships and perception. And, third, they have the ability and willingness to lean in to discomfort and vulnerability.

During these unprecedented times, we find ourselves rebounding more frequently. Today’s challenges require near moment-to-moment adaptation. While we may feel sensitive and vulnerable, athletes and performers are robust. Driven by challenge, each of us have demonstrated incredibly grit and perseverance to reach the position we are at today, overcoming injuries and obstacles. It’s important to acknowledge any feelings of distress, but equally important to have an arsenal of resources to continue moving forward in a healthy fashion. We’ve pulled together our favorites from the author / coach duo behind The Growth Equation, as well as the mental health professions at IADMS:

Practice compassion, for yourself and others

Each new 2020 challenge has shown value of human compassion. If you’re feeling overwhelmed, look to ways you can help someone or look for ways someone else has helped you recently. Being kind to yourself when things don’t go as planned is essential, too!

Stop resisting what’s happening

We’ve all been there. But wishing this wasn’t happening isn’t going to help the situation or your mental state. Focus on what your next three tasks are, and keep cycling through your day.

Focus on what you can control

Rather than worrying about the uncontrollable, put your energy towards productive action. If your league now requires mask usage for competition, build a schedule that allows you to gradually build up tolerance to it while exercising.

Think adaptation, not change

“Change is something that happens to you. Adaptation is something that you are in conversation with.” Stulberg’s view returns control to the individual, and the tasks at hand. What is non-negotiable for you, your family, or your team? Start with these, and work backwards to find to solutions that suit your current challenges. Maintaining an openness to new experiences can help to keep you on track- what opportunities has this scenario brought you?

Practice positivity and gratitude

With so much bad news floating around, it’s easy to get lost in it. When you noticed a persistent negative thought, try to reframe it. For example, maybe you still can’t take that trip you’ve been longing for, but airlines and tourism industries are working hard to provide rapid test options.

If you find yourself getting worked up, try what Stulberg refers to as the 4 P's: pause, process, plan, proceed. This quick exercise allows you to acknowledge whatever is coming up for you, and choose a response that best suits our ever-changing environment.

Finally, tap into memories that remind you why it’s all worth it. The view at the summit, that game winning shot, the performance where everything just clicked. Visualization can help to reignite feelings of purpose.

Use Routines to Anchor you

Some days, internal strategies just won’t be enough. These are the days to lean heavy on your routine lifesavers. Block off 15m breaks to take a walk around the block, schedule tech-free time at the beginning and end of your day, pre-order that instagram worth salad + juice combo. Learn what helps you be your best self on bad days. After all, “creativity resides at the heart of human resilience. Even though adversity will always exist within the human condition, embracing the creative resources within us allows us to not only endure but to prevail.” -Creativity, Trauma, and Resilience by Paula Thomson and S. Victoria Jaque.

To learn more about the connection between stress and injury, check out this article.

The Future of Disc Pathology Treatments

NSAIDs and rehabilitative care are the first line of treatment for the majority of low back pain patients. When appropriate, epidural injections can be utilized to reduce inflammation and allow for improved tolerance for exercise. Surgery is considered with severe disc herniations or when conservative care fails.

Given the prevalence of disc injuries, science is constantly searching for new strategies to treat patients. In recent years, there has been research in the potential for replacing and re-growing intervertebral discs! Two of these novel methods are stem cell therapy and gene therapy.  

Stem Cell Therapy

Currently, the best surgical strategy for severe disc injuries is either spinal fusions or disc removal. Both result in decreased function, and can have long term effects on joint health. Stem cell therapy aims to provide an alternative solution, either surgically or through injections. Cells from bone marrow tissue and adipose tissue have show the ability to develop into a structure very similar to the nucleus pulposus. Research hypothesizes that these cells can be used to grow vertebral discs in a lab, or be injected to support disc regeneration.

In a 2019 systematic review by Meisel et al, the team of researchers looked at stem cell therapy for the treatment of disc degeneration. They found the strength of the current evidence to be poor due to the low number of studies and that all reviewed studies were small and primarily case series. It was recommended that larger, more robust studies be performed to accurately evaluate this potential new treatment. 

Gene Therapy

Researchers argue that it is almost impossible to stop the progression of degeneration once it’s be diagnosed. Disc tissue lacks the regenerative properties that other cells in our bodies possess, and their low supply of oxygen and nutrition further challenges cell survival. Injecting genetic material in to very specific cells can alter this pattern, and help extend the life of spinal discs. There are several methods for this process, however RNA interference stands out as the best possible strategy currently.

A 2020 paper by Takeoka et al. proposes in depth the potential for gene therapy as a treatment strategy for degenerative disc disease. Despite listed obstacles, they assert “the amount of research is increasing and broadening, and so it is not unrealistic to expect a breakthrough from these studies over the coming few years.”

Both cutting edge procedures are still in the early stages of development, but show promise. However, medication nor surgery will never be the sole solution. It’s essential to assess your movement patterns, and address any strength imbalances or weakness.

To learn more, check out these articles:

1. Meisel HJ, Agarwal N, Hsieh PC, et al. Cell Therapy for Treatment of Intervertebral Disc Degeneration: A Systematic Review. Global Spine J. 2019;9(1 Suppl):39S‐52S. doi:10.1177/2192568219829024

2. Takeoka Y, Yurube T, Nishida K. Gene Therapy Approach for Intervertebral Disc Degeneration: An Update. Neurospine. 2020;17(1):3‐14. doi:10.14245/ns.2040042.021

Lumbar Disc Pathology: Part II

If you’ve experienced a disc injury before, you’ll know immediate care is all about triaging. You need strategies to help you deal with the pain now and a plan to tackle this ASAP! Depending on your symptoms and how you got hurt, we recommend making appointments with both your physician and a rehabilitation specialist.

A physician will be able to write prescriptions, as appropriate, while ATs and PTs will be able to address your pain from a mechanical perspective. There is tons of evidence supporting various treatment modalities for the management of lumbar disc pathologies. The focus is pain resolution, restoration of function and any associated neurologic deficits associated. 

At your appointment, your clinician will perform an in-depth evaluation and establish a treatment plan to address your specific and unique symptoms. This will often include:

• Mobility exercises for muscle, joint, and even nerves

• Stabilization exercises focused on trunk control and strengthening

• Proprioception, coordination, and balance training

• Functional conditioning 

• Phased return to sport / activity program

While you’re waiting for your appointment, there are several strategies you can try to safely mitigate your symptoms. Often, disc-related low back pain is aggravated by prolonged flexion, or bending at the waist.

1. Try to limit time sitting by standing or walking when you can.

2. Modify your work environment to allow for standing, taking seated breaks as needed. Get creative- using books, boxes or other household items to create an make-shift ergonomic solution.

3. When sitting, use a pillow or support behind your low back to limit rounding of the low back, or slumping.

4. Raising your seat height, whether in a desk chair or in the car, can help you avoid a posterior tilt of the pelvis. This position puts stretch through the muscles and nerves of the low back.

5. Rest lying down if unable to tolerate sitting. Try bending your knees, planting your feet on the ground to help maintain a neutral spine.

6. Use heat to help relax muscle spasm or guarding.

7. Avoid intense stretches for now- while they may feel good in the moment, this can increase muscle spasm.

8. Over the counter pain meds such as NSAIDs can help reduce pain. Double check each individual brand for dosage recommendations.