Rev. bras. ortop. vol.51 número1

rev bras ortop.2016;51(1):105–108

w w w . r b o . o r g . b r

Case

Report

Presence

of

a

long

accessory

flexor

tendon

of

the

toes

in

surgical

treatment

for

tendinopathy

of

the

insertion

of

the

calcaneal

tendon:

case

report

夽

Nelson

Pelozo

Gomes

Júnior,

Carlos

Vicente

Andreoli

_,

_Alberto

_de

_Castro

_Pochini,

Fernando

Cipolini

Raduan,

Benno

Ejnisman,

Moisés

Cohen

UniversidadeFederaldeSãoPaulo(Unifesp),SãoPaulo,SP,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received31December2014

Accepted28January2015

Availableonline21December2015

Keywords:

Tendinopathy Ankle Foot

a

b

s

t

r

a

c

t

Thepresenceofaccessorytendonsinthefootandankleneedstoberecognized,giventhat

dependingontheirlocation,theymaycausedisordersrelatingeithertopainprocessesor

tohandlingofthesurgicalfindings.Wedescribethepresenceofanaccessoryflexortendon

ofthetoes,seeninsurgicalexposurefortransferringthelongflexortendonofthehallux

tothecalcaneus,duetothepresenceofadisorderoftendinopathyoftheinsertionofthe

calcanealtendoninassociationwithHaglund’ssyndrome.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora

Ltda.Allrightsreserved.

Presenc¸a

do

tendão

flexor

acessório

longo

dos

dedos

no

tratamento

cirúrgico

da

tendinopatia

insercional

do

tendão

calcâneo:

relato

de

caso

Palavras-chave:

Tendinopatia Tornozelo Pé

r

e

s

u

m

o

Apresenc¸adetendõesacessóriosnopéenotornozelonecessitadeseureconhecimento,

vistoque,adependerdalocalizac¸ão,podemgerarafecc¸ões,sejaemprocessosálgicosou

nomanuseiodoachadocirúrgico.Descrevemosapresenc¸adotendãoflexoracessóriodos

dedosnaexposic¸ãocirúrgicaparatransferênciadotendãoflexorlongodoháluxparao

calcâneonavigênciadeafecc¸ãodetendinopatiainsercionaldotendãocalcâneoassociado

àafecc¸ãodeHaglund.

©2015SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora

Ltda.Todososdireitosreservados.

夽

WorkperformedintheDisciplineofSportsMedicine,DepartmentofOrthopedicsandTraumatology,EscolaPaulistadeMedicina

(EPM),UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:andreolicruz@uol.com.br(C.V.Andreoli).

http://dx.doi.org/10.1016/j.rboe.2015.12.003

106

Introduction

Tendinopathyoftheinsertionofthecalcanealtendonwithor

withoutassociatedboneexostosisorHaglund’sdeformityisa

conditionthatisdifficulttotreatanditmaycausefunctional

incapacityandlimitationofathletes’performance.1

Thisconditioninvolves tendondegeneration in

associa-tionwiththickeningofthebursaandthetissuessurrounding

thetendon,togetherwithmechanicalpressureexertedbythe

boneprominence,withdiminutionoflocalvascularization.1

Whenthisconditionissevere,thepercentagesuccessthrough

conservative treatment is low. One treatment option is

to transfer the long flexor tendon of the hallux to the

calcaneus.1,2

Thelongflexorofthehalluxischosenbecauseithas

suf-ficientlength,it isdurable, it isstrongerthan the fibularis

tendon,itscontractionforceaxisissimilartothatofthe

cal-caneal tendonand maintainsthe musclebalance and it is

closetothecalcanealtendon,whichfacilitatesthe surgical

procedure.1,2

Thesurgicalprocedureisperformedinassociationwiththe

necessarydebridementoftheentireareaofdevitalized

tendi-nosisofthecalcanealtendon,withexostectomyorostectomy

oftheposterosuperiorprocessofthecalcaneus,until

decom-pressionoftheentirecalcanealtendonhasbeenachieved.In

thecasepresentedhere,weusedthetechniqueoftransferring

theflexortendonofthehalluxtothecalcaneus,withtendon

harvestingabovethemalleolus1_{andfixationofthelongflexor}

tendonusinganinterferencescrewanteriorlytotheinsertion

ofthecalcanealtendon.Throughthistechnique,the

connec-tionsorlinksofthedistalstumpofthelongflexortendonof

thehalluxwiththeflexortendonofthetoesaremaintained

intact.

Theaimofthiscasereportwastopresentasurgical

find-ingofanaccessorylongflexortendonofthetoes,superficially

andlaterallytotheflexortendonofthehallux,duringa

trans-fer procedureto treattendinopathy ofthe insertionofthe

calcanealtendon.

Case

report

Thepatientwas a48-year-oldman who presentedchronic

posterioranklepainofprogressivenature,duringandafter

physical activity, even at recreational level, which caused

functional limitation with regard to practicing soccer and

short-distance running. He presented pain upon

palpa-tion at the insertion of the calcaneal tendon and antalgic

gait.

Radiographyshowed calcificationattheinsertionofthe

tendon and magnetic resonance imaging showed

tendi-nosis and partial injury of the tendon at the insertion

of the calcaneal tendon (Fig. 1). After clinical

examina-tion and complementary examinations, the condition was

diagnosed as tendinitis of the insertion of the calcaneal

tendonwithHaglund’sdeformityandsignificantassociated

tendinosis.

After eight months of conservative treatment

compris-ingspecific physiotherapy,hydrotherapyand analgesicand

anti-inflammatorymedications,itwasdecidedtoimplement

surgicaltreatment.Thiswasplannedtoincludetransferofthe

longflexortendonofthehallux,posterosuperiorostectomyof

thecalcaneusanddebridementoftheentiredevascularized

andfibroticregionofthecalcanealtendon.

Thepatientwaspositionedinpronedecubitus,a

tourni-quet was applied at the root of the thigh after spinal

anesthesia,asepsisandantisepsiswereperformedand

ster-ilefieldswereemplaced.Aposteromedialincisionwasmade,

goingfromthemuscle-tendontransitionofthecalcaneal

ten-dontothedistalinsertion,withlateralcurvatureforabetter

approachtotheinsertionandboneexostosis.

Dissection was performed in layers, with rigorous

hemostasis,andthesubcutaneoustissuewaspreserveduntil

theparatendonwasviewed.Aninspectionwasmade,andall

ofthedevitalized,calcified,degeneratedandamorphous

tis-sue atthe insertionofthe calcanealtendonwas debrided.

Posterosuperior ostectomy of the calcaneus was then

per-formeduntiltotaldecompressionofthecalcanealtendonhad

beenachieved.

Afterpushingthecalcanealtendonbacksuperiorlywithin

the surgicalexposureafterits deinsertion, it wasobserved

thatananomalousflexortendonwaspresent,superficiallyto

thedeepfascia,withamusclebellygoingfromwhereitwas

viewedproximallyinthesurgicalfieldtowhereitwentbeyond

theankledistallyandacquiredtheshapeofatendon,withits

ownfibrousbonetunnel.

Fromitslocation,itwasidentifiedasananomalous

acces-sorylongflexortendonofthetoes,withanatomicalvariation

suchthatitwasnotindirectcontactwiththe

neurovascu-larbundle.Thistendondidnotpresentanydegenerativeor

fibroticalterationtoitsmorphology.Itwasfoundthrough

sur-gicalexposureanddidnothaveanydirectrelationshipwith

theetiology oftheconditioninquestion(Fig.2).Theentire

lengthoftheanomaloustendonwasthenresected.Thedeep

fasciawasopened,thelongflexorofthehalluxwasisolated

and identified inits tunnel, and tenotomywas performed.

Themaximumtendonlengthwasobtainedandtheankleand

halluxremainedwithmaximumflexion.

Atthisstage,tenodesisofthelongflexorofthehalluxwas

performedatthecalcaneus,usinga7.00mmbioabsorbable

interferencescrewslightly anteriorlytothe previous

inser-tionofthecalcanealtendon,withtheankleat15◦_ofequinus.

The debrided calcaneal tendon was reinserted using bone

anchors. Afterclosure of the incision in layers, a dressing

andaplastercastsplintat15◦_{ofequinuswereapplied.The}

patientbeganphysiotherapyafterthreeweeksoffixed

immo-bilization, atwhichtimethiswasexchangedforremovable

immobilization.Partialloadbearingwasauthorizedafterfive

weeks.

Discussion

Fivedifferentanomalousmusclesinthefootandanklehave

beendescribed3,4_{:intheposterolateralregion,thetendonof}

thefourthfibularis;intheposteromedialregion,thetendons

oftheinternalfibulocalcaneal ligament;the longaccessory

flexorofthetoes (quadratusplantae); theinternal

rev bras ortop.2016;51(1):105–108

107

Fig.1–T2magneticresonanceimagingshowing(left)tendinitisoftheinsertionwithdegenerationandtendinosisofthe calcanealtendon;and(right)theaccessoryflexortendonofthetoesatitsmusclebellyisidentifiedthroughthestraight arrowontheleft,whilethelongflexorofthehalluxisalsoidentifiedthroughthearrow.

Anomalousmusclesinthefootandankleusuallydonot

causesymptoms,but insituations ofexcessiveoverloading

suchasamongathletes,thesemusclesmaycausepain,

insta-bility and joint blockade.4,5 _{Ankle conditions in which the}

masseffectofthe accessorytendonscangiveriseto

com-pression and posterior impact of the ankle, tarsal tunnel

syndrome,halluxflexorsyndromeand chronicpain

subse-quenttosprainsmayoccur.3–6

Magneticresonanceimagingexaminationsare

fundamen-talforelucidatingposteriorankleconditions, inidentifying

them,makingdifferentialdiagnoseswithtumorsand

choos-ingthesurgicalroute.3,6,7_{Theseanomalousmusclesmaynot}

beidentifiedeveninmagneticresonanceimaging

examina-tions,iftheradiologistisnotfamiliarwiththelocalanatomy.3

However,whentheyaresymptomatic,thereisusuallyahigher

leveloffluidsinthemusclesheath.3

Throughanatomical studies,accessorylong flexor

mus-clesofthetoes(alsoknownasthelongaccessoryofthelong

flexors,quadratusplantae,Turner’saccessoryorHumphrey’s

secondaccessory)3,8 _{havebeenfoundtooccurfrequentlyin}

othermammals.However,thedifferenceisthatinhumans

theyhavetwoheadsattheirorigin,representingsuccessive

stagesofthe lower pathoftheflexortendonofthehallux

towardtheplantarregionofthefoot,whilethereisasingle

musclebellyinothermammals.Themedialheadisfound

exclusivelyinhumans.9,10

Thisisthesecondmostfrequenttypefoundinanatomical

dissectionsafterthefourthfibularis.6,8 _{Becauseofproximity}

andconsistency inrelationtothe neurovascular bundleof

thetibialnerve,thetibialflexormaycausetarsaltunnel

syn-drome.Itpresentsgreatvariety,bothinitsorigin(tibia,fibula,

interosseousmembraneorlongflexorofthetoes)andinits

108

insertion(longflexorofthetoesatseverallevels,orquadratus

plantae).5–7

Itrunsbelowtheretinacularflexorandhasitsownsheath

and osteofibrous canal, and it usually becomes tendinous

whenitentersthetarsaltunnel.5–7,9_{Itmaybelateralormedial}

tothelongflexorofthehalluxattheleveloftheankleand

inferiortotheneurovascularbundlethatischaracteristically

atitsmusclebelly.Itrunsdistallyandlaterallytotheflexorof

thehallux,suchthatitusuallyhasitsinsertionintheflexor

ofthetoes.7

Thelong flexortendonofthe halluxhasbeenclassified

throughanatomicaldissectionintothreetypes,accordingto

its origin and relationshipwith the bundle9_{: type}I_{– origin}

in the lower leg and muscle belly superficial to the

bun-dle,without crossingit (type Ia)or withcrossing(type I_b);

typeII–_{originwithinitsowntarsaltunnel.Thesamestudy}

foundthatthemeanlengthwas7cmandmeanwidthwas

9.6mm, and that the tendon part had a mean length of

2.6cm.9

Conclusion

Thepresenceoftheaccessorylongflexormuscleofthetoes

didnotimpedeuseoftheflexortendonofthehalluxfor

trans-ferinacaseoftendinopathyoftheinsertionofthecalcaneus

tendon.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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