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News in Brief
New President / CEO Takes Office at Yo San University. Electroacupuncture for Constipation?
6 Steps to Make 2017 Your Best Year Yet
People often ask me what defines success. Success, for me, is simple: doing exactly what you want to do in life. Whether it's the kind of practice you run, your life at home, your hobbies or something else, it's achieving anything you put your mind to.
Molecular Motors: Tiny Machines Behind the Rhythm of Life
In the clinic, we aim to restore healthy patterns of movement for qi that has gotten trapped or misdirected, or may have even collapsed. We may be focused on freeing stagnation, releasing heat or redirecting counterflow qi, but it often comes down to helping re-establish a flow of sorts.
Herbs for Digestion: The Power of Bitter
Many cultures (and indeed herbal clinicians) around the world have long respected the role of bitter herbs and foods for promoting digestion. For example, aperitifs – drinks consumed before a meal to stimulate appetite and digestion – were originally derived from bitter herbs.
Little Sticker, Big Impact
It's the end of an election year. Hilary Clinton and Donald Trump were the subject of conversation for everyone, everywhere for the entire 2016 calendar year. I don't think any of us can deny that this election affected us all very deeply on a personal level.
A Letter to the Profession from the New President at AAAOM
Volunteering for a national, nonprofit organization brings with it such highs, lows, and accomplishments, as well as a steep learning curve.
Assessing Core Stability and ROM: 5 Basic Checks
One of the first steps in addressing core stability is assessing static posture, ranges of motion, and motion of the pelvic bones, sacrum, femurs, lumbar spine and thoracic spine.
Chiro School Reunion: Whatever Happened to...?
I opened the door to the closet slowly, carefully, since I knew it contained a large number of precariously stacked file boxes. It also held numerous outdated gizmos with electrical cords of various lengths that could trip or strangle a person.
Another Chance to Make a Difference
Just a few months ago, "the worst natural disaster to strike the United States since Hurricane Sandy" hit Louisiana. During this storm, one area experienced 31 inches of rain in 15 hours as almost 7 trillion gallons of water rained down in just one week across the state.
Overuse Injuries in Young Athletes (Pt. 2)
Most overuse injuries are benign, but there are some high-risk injuries that, if unrecognized or inappropriately treated, can result in significant loss in time from the sport or even require leaving the sport.
What We Can Learn From Spine Surgery
Patients with lumbar stenosis presumably present for conservative care to improve their quality of life and avoid surgery. However, providing clear guidance to these patients can be difficult for a number of reasons.
A Q & A About Updated Codes
Yes, indeed there was an update to ICD-10 on Oct.1, 2016. This is a regular update to the diagnosis coding system and this type of update will occur every Oct. 1, just as it did when the ICD-9 system was in place.
Can a Multivitamin Reduce Breast Cancer Recurrence?
There is a great deal of controversy regarding the value of multivitamin supplements in cancer prevention. However, with respect to preventing breast cancer recurrence, an important study was published in the Journal of Breast Cancer Research and Treatment in 2011 by Kwan ML, et al.
A First for the Profession: CCE Accredits First Chiropractic Residencies
The Council on Chiropractic Education (CCE) has awarded accreditation to all five chiropractic residency programs currently administered at Veterans Administration facilities, "the first residency programs in the nation ever to be awarded this distinction, a significant advancement in the evolution of chiropractic education," according to a VA press release announcing the milestone.
Meshing TCM With Environmental Pediatrics: Where's the Overlap?
Pediatrics has a long history within Chinese medicine dating back to the late Han dynasty (i.e., the late 200s CE), with the two primary areas of emphasis being herbal medicine and xiao er tui na (pediatric massage).
Dedicated to Defending Chiropractic
Whether you're a veteran DC or a first-trimester student, the name George McAndrews should be part and parcel of your professional vernacular, as familiar as the word chiropractic.
A Simple Protocol for Holiday Stress
It's winter, a time when we should be deep in reflection, eating warming foods and sleeping long hours. Following nature's rhythms, we restore our bodies and minds in preparation for the renewal of spring.
Branding: Set Your Practice Apart
Dr. Brad started his practice seven years ago on a shoestring budget. He created his generic logo in five minutes using a website because he didn't have the time to figure out how to make something special.
2016: A Year in the Life of Acupuncture
Happy Holidays, may you, your family and friends have peace, joy and blessings throughout this special time of year. As 2016 comes to a close, we can look back and celebrate the many events and accomplishments for the profession of acupuncture.
End of an Era Looms at NYCC
New York Chiropractic College recently announced that Dr. Frank Nicchi will retire in August 2017 after 36 years with the college, the past 17 as president.
DVT: Know the Signs and You Could Save a Life
I lost a friend several months ago. He died from a pulmonary embolism (PE) secondary to a deep-vein thrombosis (DVT) that originated in his lower leg. Bobby was in his mid-60s, soft-spoken and had a big heart.
Southwest Acupuncture College Brings It to Division 1 Athletes
When Michael Phelps' photograph with the distinctive round marks left by cupping went viral, the Division 1 student athletes treated through the Dal Ward Athletic Center at the University of Colorado (CU) could relate.
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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