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      Closed atraumatic complete rupture of the flexor halluces longus tendon during forward lunge exercise : A case report

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          Acute rupture of the flexor halluces longus (FHL) tendon due to trauma or laceration is a well-known phenomenon. Partial rupture of the FHL tendon caused by tendinitis or stenosing tenosynovitis is common in ballet dancers and athletes. However, atraumatic complete rupture of the FHL is rare: as of 2018, only 7 cases of closed atraumatic complete rupture of the FHL tendon have been reported in the literature. Here, we report on a patient who presented with a closed atraumatic complete rupture of the FHL tendon during a forward lunge exercise.

          Patient concerns:

          A 35-year-old female visited the clinic with pain in the plantar medial aspect of the left foot, along with weakness and loss of great toe flexion. The patient had a normal foot structure and no history of trauma or systemic disease. She performed a forward lunge exercise more than 50 times on 1 leg per day, more than once a week to strengthen her leg muscles. She reported that she felt a slight pain in her left, great toe while exercising for 3 weeks prior to her visit. One week prior to presentation, severe pain occurred suddenly when her left hallux dorsiflexed strongly during an anterior lunge exercise motion.


          Magnetic resonance imaging revealed complete rupture of the FHL tendon near the level of the metatarsal head and neck junction. The lesion was prolonged, with the proximal end displaced to the metatarsal shaft region.


          Complete rupture of the FHL tendon was treated with a primary suture.


          At the 1-year follow-up, active plantar flexion of the interphalangeal joint was possible but joint function had a range of 0° to 25°. Flexion strength was reduced slightly, measuring about 70% when compared to the contralateral side, but flexion strength of the metatarsophalangeal joint was normal.


          We describe an extremely rare case of complete rupture of the FHL tendon at the level of metatarsal head and neck junction. It should be understood that this injury can occur not only in professional athletes but also in the general public, and we recommend educating personal trainers on how to prevent it.

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          Most cited references 19

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          Flexor hallucis longus tendon injury in dancers and nondancers.

          Thirty-one cases of flexor hallucis longus injuries in 26 patients were treated over a 16-year period (1977-1993). Groups were divided into dance-related injuries (group I) and other causes (group II). The two groups were compared with regard to age, activity, duration of symptoms, operative findings, histopathology, and postoperative time to resumption of full activities. Twenty-seven cases required surgery for unsuccessful nonoperative treatment. In group I, 71% of patients had a partial longitudinal tear of the flexor hallucis longus compared with 30% in group II. Another common finding was isolated tenosynovitis (21% in group I and 53% in group II). Eight cases had magnetic resonance imaging (MRI) evaluations before surgery. Clinical correlation was found to be an important factor in interpreting the MRI. Dancers tended to have symptoms for a longer period of time before seeking treatment than did nondancers. Follow-up was 19.2 months for dancers and 25 months for nondancers. Surgical correction of tenosynovitis, pseudocyst, and tendon tear yielded good or excellent results in 14 of 15 dancers and 9 of 11 nondancers. Surgical treatment of tendon tears and other pathologic tendon conditions gave consistently good results in patients with refractory flexor hallucis longus disease.
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            Experimental muscle pain during a forward lunge--the effects on knee joint dynamics and electromyographic activity.

            The purpose of this study was to investigate whether the knee joint dynamics during a forward lunge could be modulated by experimentally induced vastus medialis pain in healthy subjects. Randomised cross-over study. Biomechanical movement laboratory. 20 healthy subjects were included. One subject was excluded during data collection. The subjects performed forward lunges before, during and 20 minutes after induction of experimental quadriceps muscle pain. Muscle pain was induced using hypertonic saline (5.8%) injected intramuscularly. Isotonic saline (0.9%) was used as control. Three-dimensional movement analyses were performed and inverse dynamics were used to calculate joint kinematics and kinetics for ankle, knee and hip joints. Electromyographic (EMG) signals of the hamstrings and quadriceps muscles were recorded. During and after pain, significant decreases in knee joint dynamics and EMG recordings were observed. The study shows that local pain in the quadriceps is capable of modulating movements with high knee joint dynamics. The results may have implications in the management of muscle pain and prevention of injuries during activities involving the knee joint.
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              Lacerations of the flexor hallucis longus in the young athlete.

              Of ten patients with lacerations of the flexor hallucis longus tendon, nine were athletically inclined. In four, the laceration was not repaired and no disability was evident. A functioning flexor hallucis longus, therefore, does not seem to be essential for good push-off and balance in running sports. If both the flexor hallucis brevis and the flexor hallucis longus are lacerated and reconstitution of the longus is not possible, the brevis should be repaired, suturing the distal segment of the longus to brevis to prevent hyperextension deformity of the metatarsophalangeal joint. Hypersensitivity of the scar due to associated nerve injury is a frequent complication associated with laceration of the flexor hallucis longus.

                Author and article information

                Medicine (Baltimore)
                Medicine (Baltimore)
                Wolters Kluwer Health
                December 2019
                16 December 2019
                : 98
                : 50
                [a ]Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu
                [b ]Department of Foot and Ankle Surgery, Nowon Eulji Medical Center, Eulji University, Hangeulbiseok-ro, Nowon-gu, Seoul
                [c ]Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Dongam-gu, Cheonan
                [d ]Department of Orthopaedic Surgery, Konkuk University Medical Center, Neungdong-ro, Gwangjin-gu, Seoul
                [e ]Department of Obstetrics and Gynecology, Soonchunhyang University Hospital Cheonan, Suncheonhyang 6-gil, Dongam-gu, Cheonan, Korea
                [f ]Department of Orthopaedic and Traumatology Surgery, Medicine Faculty, Soegijapranata Catholic University, Semarang, Indonesia.
                Author notes
                []Correspondence: Woo Jong Kim, Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, 31, Suncheonhyang 6-gil, Dongnam-gu, Cheonan 31151, Korea (e-mail: kwj9383@ 123456hanmail.net ).
                MD-D-19-02792 18409
                Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

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