resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Six Things Every DC Should Know About the Zika Virus
The Zika outbreak continues to spread across the continental United States and U.S. territories. We offer this brief overview on this important public health problem for the practicing doctor of chiropractic.
U.S. Olympians Have a DC in Their Corner
It's probably old news to you that doctors of chiropractic play an increasingly prominent role in treating athletes, from youth sports participants to weekend warriors, to elite / professional competitors.
Four Ways to Attract Patients
Acupuncturist A has been in practice for six years and has struggled since day one. She spends as much time and money on marketing as she can, but since her practice is slow, her budget isn't that big.
Power to the Patient
Against a backdrop of splintered political parties, polarizations within nations, civil unrest, and distrust of established government (such as the growing anti-Washington, D.C. sentiment) comes the not-so-surprising finding that health care authorities and practitioners (with perhaps the exception of insurers) are turning over more and more powers to the individual patient.
Getting Paid by Medicare Is Getting a Major Adjustment
The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law to implement a new approach to clinician payments and replace the Sustainable Growth Rate formula.
Integrative Cancer Care: Chiropractic for Chemotherapy-Induced Hiccups
Hiccups (singultus) are a frequent occurrence during cancer treatment. The cause of the hiccups may be the chemotherapy drug itself, such as Cisplatin; or the prophylactic use of corticosteroids such as Decadron, which is used to prevent nausea and/or vomiting.
ITB Syndrome: Treat the Tensor Fascia Latae
Iliotibial band syndrome is usually the result of repetitive knee flexion, such as in runners or cyclists. Pain may be experienced in the knee and/or the hip. The patient may express a sense of the hip dislocating, popping or snapping.
National Board Apologizes for Testing Issues
The National Board of Chiropractic Examiners (NBCE) has issued a formal apology following a series of computer-based testing malfunctions that impacted two separate examinations (March and June 2016) and caused "widespread confusion and frustration" to the nearly 1,500 examinees taking the tests.
Decoding the Mystery of Medical Insurance Acceptance
In the constantly evolving profession of acupuncture, one of the least understood areas is medical insurance acceptance. The profession is filled with controversy surrounding this topic: Is it ethical?
Dysautonomia: The Medical Condition You May Already Be Treating
TCM practitioners have spent thousands of years healing patients without knowing or needing the names of their diseases as defined by allopathic medicine. We have syndrome names that are both poetic and efficient.
Treating Peripheral Neuropathy: Multi-Faceted Approach Including Laser Therapy
Peripheral neuropathy affects at least 20 million people in the United States1 and nearly 60 percent of all people with diabetes suffer from diabetic neuropathy. Many suffer from the disorder without ever identifying the cause.
Pediatric Asthma: A Case Study
I have had very good success with pediatric asthma, combining acupuncture with Chinese herbal products. Treatment is given over four to eight months, twice monthly, with herbal formulas rotated every month.
Workers' Back Pain: Causes, Costs & Solution
You will want to share two important papers published in the past several months. Why? When read separately, each provides valuable information relevant to your patients, community and practice; together, they tell a compelling story.
Treatment Success at the Won Institute
According to the World Health Organization's 2003 report titled, "Acupuncture: Review and Analysis of Controlled Clinical Trials," acupuncture has been shown to improve many physical, emotional, and mental conditions.
Pediatric Footwear: Function Over Fashion
As practitioners, it is not uncommon for parents to bring us their children to treat or ask us questions related to the pediatric population. Children's feet tend to be a perplexing region for parents and practitioners alike.
Natural Cancer Prevention: Pomegranate for the Prostate
In recent years, the ingestion of pure pomegranate juice (8 ounces per day) has been shown in clinical studies with human subjects to slow, and to some degree, reverse, the progression of prostate cancer – the second leading cause of cancer death in North American men.
Update from the International AIDS Conference
The 21st International AIDS Conference in Durban, South Africa, brought together more than 15,000 of the world's leading scientists, activists, funders, policy makers, and consumers from 153 countries.
First Annual ICD-10 Updates Take Effect
Yes, there was an update to ICD-10 codes on Oct. 1. It was a regular update to the diagnosis coding system and will take place every Oct. 1, just as it did when the ICD-9 system was in place.
Going Beyond Just Feeling Good
We all know that most patients come to us for some pain complaint: neck pain, back pain, sciatica, carpal tunnel, etc. We also all know that acupuncture is a great first-line care for these issues, as well as supporting overall health and wellness.
Upgrade to "Parker 2.0" in Las Vegas
Continuing your education and refining your practice: two key elements of a successful chiropractic career. Parker Seminars promises both as it celebrates its 65th anniversary in Las Vegas next February, according to Parker University President, Dr. William Morgan, and seminar consultant Dr. Mark Sanna.
Using the Lens of Chinese Medicine
One of the most common medications I see in clinical practice on a daily basis is fluoxetine or Prozac. Consequently, I hear many complaints concerning the side effects of this medication and am frequently asked by patients to help manage these side effects with acupuncture and Chinese medicine.
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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