In a previous installment of this column, we discussed dysfunction of the flexor hallucis longus (FHL) muscle. Our discussion covered the basics of the condition and some primary assessment principles. However, it's also important to have appropriate strategies for treating the problem. This article covers specific technique suggestions that are valuable in addressing this challenging lower extremity problem.

Traditional medical approaches for addressing FHL dysfunction may advocate treatments such as corticosteroid injections. Keep in mind that one component of the FHL dysfunction may involve stenosing tenosynovitis, a narrowing of the synovial sheaths around the affected tendon. Some medical practitioners advocate the use of anti-inflammatory medications because there can be inflammatory activity with the tenosynovitis.

Despite the fact that there is often an inflammatory component with this problem, as in the case of stenosing tenosynovitis, corticosteroid injection is usually contraindicated due to the very close proximity of the neurovascular bundle. There is a risk of potential nerve or vascular tissue damage by using injections so close to neurovascular structures. Avoidance of corticosteroid injections is also a good idea because they can lead to long-term collagen degeneration in the tendon, which is detrimental for optimum tendon function.¹

FHL dysfunction can usually be treated with conservative measures, and soft-tissue treatment is a mainstay of the conservative approach. Massage is helpful as a non-invasive way to address the biomechanical dysfunction as well as the primary tissue pathology. One of the most helpful methods for addressing this problem is deep longitudinal stripping techniques applied to the FHL and deep posterior compartment muscles. (Fig. 1) This technique can be performed in several positions. A side-lying position is particularly effective and is shown here. Use the thumb, fingertip or other small contact surface to apply a slow but deep stripping technique along the medial tibial border directly on the deep posterior compartment muscles such as the FHL. This can be quite tender so make sure you go slowly and stay in close communication with your client about appropriate pressure levels.

Friction techniques applied to the medial side of the ankle may be helpful to mobilize the tendon against adjacent tissues in the region. However, be cautious about the amount of pressure used in this area as there may be corresponding compression of the tibial nerve on the medial side of the ankle and you don't want to aggravate that problem.

Deep stripping with a small contact surface such as the thumb, knuckle, fingertip, or pressure tool should also be performed to the tendons and muscles on the bottom surface of the foot. As mentioned earlier, sometimes there may be adhesions developing between the tendons of the FHL and flexor digitorum longus (FDL) on the bottom of the foot. These adhesions can be broken up by good friction and stripping techniques. The client should also be encouraged to stretch the FHL frequently in order to encourage better mobility. Stretching is best performed in the same position that is used to stretch the gastrocnemius and soleus muscles (Fig. 2). This stretch can also emphasize the FHL a little more and discount any tightness in the gastrocnemius by flexing the knee and hyperextending the hallux during the stretch.

Another technique that is highly effective for FHL dysfunction is an active engagement stripping technique to the deep posterior compartment muscles. You will use a similar stripping technique to the one mentioned earlier. However, active movement is used in conjunction with the stripping technique.

Begin with the client's muscle in a shortened position. That means the foot is in a plantar flexed position. Use the side-lying position shown in Figure 1 because it allows for full movement of the foot. Have the client perform an active plantar flexion and dorsiflexion movement that is slowly repeated. Each time the client dorsiflexes, the foot performs a short stripping method on the FHL muscle. The stripping technique is applied each time the muscle is elongating. Release pressure as the client moves the foot back into plantar flexion. Repeat that sequence of movements until you have covered the entire muscle group thoroughly. If there are areas that are particularly tender, repeat the technique several times in those areas until muscle tightness or fibrosity has been adequately reduced. This active engagement technique is highly valuable for any overuse disorders of the lower extremities that affect the deep posterior compartment muscles.

If conservative treatment is not effective for this problem, surgery may be performed in some cases. Surgical procedures usually consist of tenolysis, a procedure where the tendon is freed from scar tissue or entrapment by adjacent structures. Following the surgical procedure, adequate mobilization of the FHL will be important and massage can play a significant role in the post-surgical management of this condition as well.

This problem or group of problems, known as FHL dysfunction may occur more often than realized because the symptoms are so similar to other pathologies. The massage practitioner is encouraged to thoroughly evaluate this condition, including detailed information from the client history, in order to determine if the problem will respond well to soft-tissue treatment. Because this is such a specific muscle/tendon pathology, massage may offer great results for successful resolution and a return to pain-free movement.

To see a demonstration of the active engagement technique for deep posterior compartment muscles described in this article, go to this YouTube video: www.youtube.com/watch?v=U1qVge1TGIo

Reference

1. Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med Sep 2005;15(5):370-5.