The flexor hallucis longus tendon travels through a fibro-osseous tunnel behind the medial malleolus, under the sustentaculum tali, and through a tendon sheath beneath the great toe to its distal phalanx insertion. It is the principal power tendon of the great toe and a critical component of the toe-off mechanism in walking and running. Its tunnel behind the medial malleolus is a common site of tenosynovitis in ballet dancers and distance runners.
Great toe push-off power; medial longitudinal arch support during propulsion
FHL tenosynovitis produces posteromedial ankle pain with great toe movement, classic in ballet dancers who work in extreme plantarflexion (en pointe) that repeatedly compresses the tendon in its tunnel. The FHL stretch test of passive great toe dorsiflexion with the ankle in neutral is the specific provocation. A hallux trigger or clicking great toe occurs when stenosing FHL tenosynovitis prevents smooth tendon gliding. Surgical release of the fibro-osseous tunnel is performed for refractory cases.
Inflammation within the FHL fibro-osseous tunnel producing posteromedial ankle pain with great toe movement, classic in ballet dancers and reproduced by the FHL stretch test of passive great toe dorsiflexion.
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