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B Vitamins Improve Memory, Prevent Brain Atrophy
The 2010 OPTIMA study showed that the accelerated rate of brain atrophy in elderly with mild cognitive impairment could be slowed via supplementation with homocysteine-lowering B vitamins, which included folic acid, vitamin B12 and vitamin B6.
Avoid Random Treatment of Trigger Points (Part 2)
We must acknowledge that the fascia, which surrounds literally everything in our bodies, including every muscle fiber, is more than just a covering.
Synergy Doesn't Happen in Silos: Acupuncture in Hospitals and Other Healthcare Settings
As acupuncture and traditional East Asian medicine continue to intersect and integrate with biomedical approaches, the conversation about integration expands and becomes richer.
An Excerpt from TCM Case Studies: Pediatrics
This excerpt is reprinted with permission from Jamie Wu. TCM Case Studies: Pediatrics was released in 2014 by People's Medical Publishing House.
Will You Be an Amplifer or a Mute?
These times are changing, and changing quickly. There have been many challenges to this profession throughout the past few years. The challenge is to talk, then talk and talk some more about this medicine.
Expanding Access, Branch by Branch
The big news coming from Capitol Hill isn't merely the recent introduction of a pair of bills designed to expand chiropractic services in the Veterans Affairs and military health care systems; after all, similar legislation has made its way through Congress before, never reaching the Oval Office for presidential signature.
A Well-Kept Secret: 5 Element Acupuncture, Part II
Supervising acupuncture interns at a TCM college, it has always struck me how funny it is to hear the clinic manager tell the patients that the Five Element clinic specializes in treating emotions, as if patients with physical pain have no emotions!
The Way We Are Designed: A Conversation with Gil Hedley, PhD
I was first introduced to the work of Gil Hedley by Tom DiFerdinando. He gifted me Gil's DVD series.
Help Update the LBP Practice Guideline
The Council on Chiropractic Guidelines and Practice Parameters has announced the release of an updated Clinical Practice Guideline for Chiropractic Management of Low Back Pain for stakeholder review and comment.
Converting More Patients to Your Practice
In 2013 and 2014, the theme was "the money is in the list." This meant that if you had a big email list, you were really making some "cha-ching." Unfortunately, having thousands of emails doesn't equate to thousands of dollars in profit.
TCM Congress in Rothenburg is Largest in Western World
In the medieval town of Rothenburg, deep set within the Bavarian countryside in Southern Germany, the TCM Kongress Rothenburg each year draws around 1.200 participants from more than 40 different countries to attend the biggest TCM conference in the Western world.
Impacting Chiropractic's Future With Technology
When it comes to electronic health records (EHR), Robert Moberg and Dr. Steven Kraus are two of the leading industry experts on the topic.
A Reality Check – and a Chance to Educate
Imagine working in the public relations department of nutrition retailer General Nutrition Corporation (GNC) and reading the The New York Times announce...
There Really is No Room for Sexism
Recently, Matteo* (a transgender male) approached me during a break in an advanced shiatsu class in Berlin where he was one of two men in a group of 20 women. "Pamela. Don't forget to remind the translator to include male endings."
Treating Beyond Pain
More often than not, when a patient presents to the office, it is for a pain complaint. Headache, neck pain, low back pain, sciatica, carpal tunnel... The pain is often the focus of the patient's mindset, and they don't often have any thought of what comes after the pain.
Recreational Cannabis Use and TCM
Many people are drawn to cannabis for its effects physically, mentally and emotionally. Medically, cannabis has some legitimate uses, however the scope of this article is limited to the recreational use of cannabis.
Primary Spine Care: Addressing Concerns & Criticisms
The Dec. 1, 2013 issue of Dynamic Chiropractic included an article describing the implementation of a training program for primary spine practitioners (PSP) within a metropolitan region and supported by a large BC/BS plan.
The Need for a New Medical Model: A Challenge for Biopsychosocial and Ecopsychologica Medicine
Chinese medicine speaks of alignment between humans, heaven and earth. It is a complex view with a focus upon relationship. These are comprehensive ideas with no specific terms in contemporary medical practice.
Interpersonal Skills 101: Enhancing the Value of Our Patient Interactions
Recently, I read an interesting article in our local newspaper titled "The Value of Human Interaction." The article presented comments from a senior editor for Fortune magazine who discussed "Civility in the Business World."
The Dietary Supplement Research Dilemma
I do not care what the truth is, one way or another; I just want to know it. And when it comes to dietary supplements, the truth can be hard to find for a number of reasons.
Low Back Pain: Posture and Movement Analysis
When performing static and dynamic movement analysis of the lumbopelvic hip area, begin with standing visual posture analysis of the pelvis, and then perform lumbar range of motion and assess what you might see during normal versus abnormal lumbar flexion motion.
Atypical Femoral Fractures and Bisphosphonate Use: What to Watch For
Bisphosphonates (BP) are popular drugs, with more than 8 billion in sales in 2008; however, profits have declined as patents began expiring. Nonetheless, BP remain the most commonly prescribed drugs for patients at risk of osteoporotic fractures, with several million prescriptions written every year.
January, 2010, Vol. 10, Issue 01
Flexor Hallucis Longus Dysfunction
By Whitney Lowe, LMT
Soft-tissue foot pain is widespread, especially in active people. Problems such as plantar fasciitis, Achilles tendinitis, or tarsal tunnel syndrome are common causes of chronic pain and disability.However, another muscle in the foot should be considered when investigating medial ankle or plantar-surface foot pain. Disorders of the flexor hallucis longus (FHL) are routinely overlooked and may frequently be misdiagnosed as some of these other foot problems mentioned above.1
The proximal attachment of the FHL is on the distal 2/3 of the posterior fibula and the interosseous membrane. It is one of three muscles in the deep posterior compartment of the leg, and shares that compartment with the tibialis posterior and flexor digitorum longus (FDL). These muscles course together through the tarsal tunnel on the medial side of the ankle (Figure 1). The FHL's distal attachment is on the plantar surface of the hallux (great toe).
Along its path, the tendon must curve around the sustentaculum tali, a prominent bony landmark on the medial side of the foot (Figure 1). One common cause of FHL dysfunction is friction and irritation of the tendon at this site. The FHL tendon also passes between two sesamoid bones at the metatarso-phalangeal joint where the first metatarsal meets the hallux. Irritation of the tendon or its synovial sheath can also occur at this area.1
The FHL muscle is difficult to palpate along most of its length because it is so deep in the posterior compartment. It is easier to palpate around the medial malleolus near the tarsal tunnel. It is the most posterior of the three tendons that curve around the medial malleolus. When palpating in an anterior direction from the Achilles tendon on the medial side of the heel, it is the first tendon encountered (Figure 1). The tendon also becomes more prominent to palpation during resisted toe flexion.
In most cases of FHL dysfunction, normal anatomical structures are the root of the problem. However, anatomical anomalies can account for the same symptoms as well. These anomalies may not be identifiable without more detailed investigation such as MRI. For example, one author reported a case where there were persistent symptoms of FHL dysfunction that did not respond to conservative treatment. Upon surgical investigation, the patient was found to have an accessory FHL muscle that could account for the larger muscle mass and symptoms of irritation resulting from activity.2 This anomaly may not be as rare as it seems because it has appeared in other references as well.3-4
The most common problems with the FHL are tenosynovitis, muscle strains and tendinosis. These conditions often occur together due to constant friction or irritation of the muscle. As a result, the collection of these conditions is sometimes called flexor hallucis syndrome.1,5
Of these different pathologies, stenosing tenosynovitis is the most common. Stenosis means narrowing, and tenosynovitis is an inflammatory irritation between the tendon and its surrounding synovial sheath. Not all tendons are surrounded by a synovial sheath so tenosynovitis only occurs in certain tendons. Most tendons with a synovial sheath are found near the distal extremities as they pass under a binding retinaculum (Figure 1). In FHL dysfunction, stenosing tenosynovitis occurs at the tendon's narrow channel where it passes the posterior aspect of the talus and the sustentaculum tali. Repeated pressure against these surfaces causes irritation.
Stenosing tenosynovitis of the FHL is reported most commonly in ballet dancers, but also occasionally in runners.4,5 High levels of tensile stress are placed on the FHL when the dancer goes en pointe (Figure 2). In this position, there is a forceful plantar flexion as the entire weight of the body is being borne on the tips of the toes. The toes are held in flexion and the foot is in extreme plantar flexion. The strong tensile load on the FHL tendon may cause irritation when it is pressed against the sustentaculum tali.
A condition called hallux saltans may also develop as part of FHL overuse. Hallux saltans is the development of a nodule along the FHL tendon and/or its sheath. This nodule may produce a sort of popping effect of the hallux during contraction and elongation because the nodule drags across adjacent tissues. The popping sensation is the same process that occurs with trigger finger in the hand. This popping or triggering is accentuated by friction between the nodule and the flexor retinaculum that lies immediately superficial to the tendon (Figure 1).
Problems may occur with the FHL tendon on the plantar surface of the foot as well. Scar tissue from tendon irritation or plantar fasciitis may cause the tendons of the FHL and flexor digitorum longus (FDL) to adhere to each other (Figure 3). Adhesion between these structures is evident if there is a significant clawing of the other toes when the FHL is activated during attempted flexion of just the great toe.
In addition to problems with the tendon and the tendon sheath, the FHL is susceptible to overuse muscle strains near the distal musculotendinous junction. In the FHL, the distal musculotendinous junction is located just posterior to the medial malleolus. Strains in this region may be accentuated by friction forces of the muscle and tendon against the posterior aspect of the tarsal bones just before the tendon enters the tarsal tunnel.
Due to its anatomical arrangement, the FHL muscle is vulnerable to many overuse conditions. However, FHL dysfunction is not as common as other foot pathologies, so problems in this muscle-tendon unit are often misdiagnosed. All of these dysfunctions can benefit from soft-tissue treatment, so it is valuable for the massage practitioner to have a thorough understanding of this pathology, as well as how to evaluate and treat it. In a future issue, we'll explore how best to identify and treat FHL dysfunction.
Click here for more information about Whitney Lowe, LMT.
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