resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Believe it or not, an estimated one-third of your patients have eaten some form of fast food within 24 hours of their appointment with you.
Multivitamin Supplement May Reduce Breast Cancer Recurrence
There is a great deal of controversy regarding the value of multiple vitamin supplements in cancer prevention.
AOM Hospital-Based Practice: A Future Reality?
The natural evolution of health care on the planet is integrative health. We may have some challenges ahead, but based on my research, all indicators are pointing in a positive direction. There seems to be an evolving consciousness among our patient population that is "getting it."
Three Tips to Help You Analyze the Acupuncture Case Studies of the NCCAOM Exam
Confirm the answer quickly by the elimination method. Case study:
After two treatments for back pain, a patient presents for a third
session complaining of rapid breathing and wheezing that is made worse
during cold weather.
Adventures with the San Jiao
Those of us who have been in practice for several decades relish the way meridians and points reveal new diagnostic clues and new insights. I love to encourage my students to see this as an adventure that goes way beyond the textbooks.
Beating the Odds: Interview With Para-Powerlifter Adeline Dumapong-Ancheta
Since October 2015, the FICS Foundation, the charitable organization affiliated with the International Federation of Sports Chiropractic (FICS), has been supporting disabled athletes internationally.
Treating Hip & Groin Pain With Abdominal Release of Upper Lumbar Nerve Impingements
Have you encountered patients with groin and hip pain you can't seem to solve? You know it's not a worn-out hip; you suspect the pain is somehow connected to the spine. But somehow, you just can't help them break through.
Acupuncture Muscle Trigger Point and Oriental Medicine Sports Therapy
It is difficult to ascertain the internal condition of professional basketball player Lebron James during game one of the 2014 NBA finals, in which he developed debilitating muscle cramps that led to his premature removal from the game.
Introducing the Acupuncture Today Digital Edition
In response to the changing habits of our readers, Acupuncture Today will introduce a digital edition of the publication (in addition to our print edition) beginning with the August 2016 issue.
What You Say Isn't Always What Patients Hear
A few years ago, my aunt Edna (name changed for the purpose of this story) suffered a stroke. After a short hospital stay, she was transferred to a nursing home for rehabilitation. When she arrived at the nursing home, Edna requested a private room.
An MD Who Understands the Opioid Epidemic
Doctors of chiropractic have an important role to play in ending the opioid epidemic and dealing with chronic pain by conservative means (see our top story in this issue) – but who's to blame for opioid dependence and abuse in the first place?
An Emerging Partnership Model
Maryland University of Integrative Health (MUIH) has educated integrative health and wellness practitioners for the last 40 years, originally as an acupuncture clinic and school. The institution's transformative, relationship-centered programs integrate traditional wisdom with contemporary science
What's New in Phytonutrition: Mangifera Indica, "The King of Fruits"
One hundred percent pure Indian green mango fruit (mangifera indica), harvested at a special degree of ripeness for efficacy and taste, can now be concentrated as a phytonutrient nutraceutical powder.
How to Stay Sane During the Elections: Understanding Through the Lens of Chinese Medicine
In Chinese Medicine philosophy, everything consists of Yin and Yang. The law of polar opposites – one cannot exist without its opposite.
Sit or Stand? Analyzing a Mixed Message
I'm more than a bit confused. At my age, that seems to be a rather common occurrence. However, today more than ever, I'm getting a mixed message.
Chronic Pain: Become Part of the Solution
I have lectured to more than 7,000 chiropractic physicians over the past five years regarding the chronic pain and opioid epidemic in this country.
Increasing the Value of Spine Care: CMS Approves New Low Back Pain Registry
The Centers for Medicare and Medicaid Services has approved the Spine IQ Low Back Pain Registry as a qualified clinical data registry for the Physician Quality Reporting System (PQRS) in 2016.
The Pertinent Negative
We all have to perform evaluations on patients. Most of us don't like doing it – exams take time, and worse it takes even more time after the evaluation to put together a narrative summary of the findings. Sometimes, this process becomes downright tedious.
Tai Chi Documentary Premier
First Run Features recently announced the world theatrical premiere of Barry Strugatz's documentary The Professor: Tai Chi's Journey West, which premiered last month at the Laemmle Music Hall in Los Angeles.
A Long-Overdue Win for Oregon Medicaid Patients - and the Implications for Other States
Beginning July 1, 2016, Oregon Medicaid patients with spinal pain (cervical, thoracic, lumbar, pelvic) who are determined to be low risk based on a biopsychosocial assessment tool (STarT Back – Keele University) can receive four chiropractic visits per episode.
Kansas Achieves Licensing Law
Kansas Governor Sam Brownback signed House Bill 2615 into law on Friday, May 13, 2016. HB2615 includes provisions for the licensure of acupuncturists in the state of Kansas.
Insuring Quality Control in Herb Importation: An Interview with Wilson Lau
Wilson Lau is the vice president of Nuherbs, a Chinese herb importation company based in San Leandro, California. Before joining Nuherbs, he trained as a lawyer specializing in FDA law.
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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