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Arthroscopic tenolysis of the flexor hallucis longus
A minimally invasive surgery that restores the gliding of the tendon in under an hour, through two small incisions at the back of the ankle. A technique proven over twenty-five years, validated by practice and by the scientific literature.
When conservative treatment is no longer enough
Surgical treatment is in principle reserved for patients whose improvement with conservative treatment was only temporary. It may occasionally be offered as a first-line option, notably for symptomatic hallux rigidus, where conservative treatment remains poorly tolerated because of the pain it causes.
The operation in itself is not a cure-all. It lays the foundations that will allow the patient to progress, which is not the case otherwise. Better footing brings better balance, and restored synchronism brings greater stability in movement. Physiotherapy follow-up often accompanies surgery to correct acquired postural habits.
A combined approach
Surgery does not act alone. It is part of comprehensive care that includes physiotherapy follow-up, sometimes the prescription of foot orthoses, and postural work to optimize the long-term benefits.
Twenty-five years of surgical practice
The history of this procedure is also that of expertise patiently built, from the first open-approach operations to today’s standardized arthroscopic technique.
First open-approach operations
Dr Jacques Vallotton operates on his first patients through a 4 to 5 cm medial retro-malleolar open approach. The tenolysis is limited to the retro-talar pulley. Some twenty cases are treated, with very encouraging results for FHL tenosynovitis and painful knee syndromes.
Meeting Prof. Niek van Dijk in Amsterdam
At the Academic Medical Center, Prof. van Dijk developed arthroscopy of the ankle and hindfoot. A collaboration begins to adapt FHL tenolysis to this minimally invasive approach.
Shift to the arthroscopic technique
FHL tenolyses are now performed arthroscopically through two portals located on either side of the Achilles tendon. The anatomy of the FHL and the configuration of the retro-talar tunnel are studied and documented over the course of practice.
Scientific publication and 1,660 operated feet
Twenty years of practice culminate in the publication of a complete description of the technique in the Journal of Arthroscopy. The count exceeds 1,660 operated feet. Experience further refines the understanding of the tendon impingement.
A standardized, reproducible technique
Endoscopic FHL tenolysis has become an international reference. The Centre du pied in Lausanne regularly welcomes surgeons in training and takes an active part in disseminating the method.
« Surgery is not an end in itself. It restores the foot’s propulsive function, and it is this recovered function that allows the entire locomotor chain to rebalance itself. »
Dr Jacques Vallotton, Centre Orthopédique d’Ouchy
Who is surgery indicated for
Because the biomechanical implications of FHL affect movement as a whole, the indications are diverse. For most operated patients, the problems involve the foot or the knee. The results are particularly spectacular for certain indications.
Indication 1
Symptomatic hallux rigidus
- Painful metatarsophalangeal stiffness
- Poorly tolerated conservative treatment
- Possible first-line indication
Indication 2
Hallux valgus
- FHL release systematically offered
- FHL regarded as the primum movens of the deformity
- Proven biomechanical benefit
Indication 3
Persistent heel pain
- Heel pain resistant to the usual treatments
- Often an unrecognized tendon impingement
- Spectacular results after tenolysis
Indication 4
Plantar or Achilles tendinitis
- FHL tenosynovitis often mistaken for it
- Wrongly diagnosed as plantar fasciitis
- Rapid benefit after release
Indication 5
Tibial periostitis
- Pain along the inner edge of the tibia
- Promoted by poor push-off
- Chain-wide improvement after surgery
Indication 6
Painful knee syndromes
- Patellofemoral pain syndrome, pes anserine tendinitis
- Iliotibial band syndrome
- Chain imbalance corrected
Additional indications
Surgery may also be indicated for overload-related foot pain, for lumbopelvic pain linked to postural imbalance, or as an adjunct to knee ligament reconstruction. In all cases, the indication depends above all on understanding the mechanical disorder caused by FHL and its role in the painful conditions.
The surgical technique in five steps
The operation aims to restore proper gliding of the FHL tendon by opening the fibrous sling at the back of the ankle. This tenolysis is performed endoscopically, with a camera transmitting live images to a high-definition screen.
Procedure
Five operative steps
Patient positioning
The patient lies face down, as the portals are posterior. Anesthesia is usually regional, sometimes general depending on the case.
Arthroscopic portals
Two incisions of a few millimeters on either side of the Achilles tendon. The arthroscope (a 5 mm tube) is introduced through the lateral portal.
Visualization and identification
The camera views the subtalar joint, identifies the retro-talar pulley, and visualizes the FHL tendon. Neighboring structures are preserved.
Tenolysis and tendon release
Through the medial portal, the instruments incise the pulley at its contact with the talus until the tendon glides freely. Any bony prominence is smoothed away.
Closure and end of procedure
The skin incisions are closed with a single stitch each. The operation usually takes less than an hour. Discharge the same day or the next day.
Key points
A procedure lasting under an hour, two incisions of a few millimeters, two stitches, a short hospital stay. The minimally invasive technique allows rapid recovery and an early return to activity.
The operation in video
Three videos give a concrete view of the surgical technique, from the general presentation to the endoscopic maneuver and the complete procedure.
Functional Hallux Limitus: the surgical technique
Endoscopic tenolysis of the flexor hallucis longus for FHL
The complete endoscopic procedure, narrated by Dr Vallotton
Scientific reference
The technique has been fully described in an international publication, which details the methodology, the portals, and the long-term results of the Centre du pied series.
Reference article
Endoscopic tenolysis of the Flexor Hallucis Longus tendon, Surgical Technique
Olden TR., Vallotton J., September 2020, Journal of Arthroscopy: The Journal of Arthroscopic and Related Surgery
Frequently asked questions
How long does the procedure take? The operation usually takes less than an hour. The patient then spends time in the recovery room before returning to their room or going home.
What type of anesthesia? Usually regional anesthesia, sometimes general depending on the case. The choice is made with the anesthesiologist during the preoperative consultation.
Do I need to stay in the hospital? The procedure is most often performed on an outpatient basis. One night of observation may be offered depending on the case.
How long is the recovery? Walking is allowed quickly with appropriate footwear. Return to non-physical work in 2 to 3 weeks, sports in 6 to 8 weeks.
Any particular risks? The minimally invasive arthroscopic technique considerably limits complications. The details are systematically discussed during the preoperative consultation.
Is a mobility assessment required beforehand? Yes, the mobility assessment is an integral part of the preoperative evaluation. It confirms the indication and establishes a baseline for measuring progress.
What results can be expected? Particularly spectacular results for hallux rigidus, heel pain, tendinitis, and painful knee syndromes. Postural work consolidates the benefits over time.
Next step
Assessing the surgical indication in your patient
The mobility assessment at the Centre du pied confirms the indication, objectively documents the initial situation, and establishes a baseline for measuring postoperative progress.
In practice
Duration
under one hour
Anesthesia
regional
Hospital stay
outpatient
Incisions
2, a few mm each
Return to walking
immediate
Return to sports
6 to 8 weeks
Going further
Related pages
Conservative treatment
The non-surgical approach, recommended as first-line care in most cases.
Mobility assessment
The preoperative evaluation that confirms the indication and objectively documents the initial situation.