Home Functional Hallux Limitus Surgical treatment Indications
Surgical treatment
Who is surgery indicated for?
FHL tenolysis is in principle intended for patients whose improvement with conservative treatment was only temporary. Because FHL affects the entire biomechanics, the indications are diverse — from hallux rigidus to painful knee syndromes.
After conservative treatment — or from the outset
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, for example for symptomatic hallux rigidus, where conservative treatment will be poorly tolerated because of the pain it causes.
Only exceptionally is surgery indicated for pain located where the tendon passes through the retro-talar tunnel. The indication depends above all on understanding the mechanical disorder caused by FHL and its role in the painful conditions for which patients seek care — patellofemoral pain syndrome, overload-related foot pain, lumbopelvic pain.
Diverse indications, from the foot to the knee
Because the biomechanical implications of FHL affect movement as a whole, the indications are highly diverse. For most operated patients in the series, the problems involve the foot or the knee. The results are particularly spectacular for:
indication
Hallux rigidus
Painful stiffness of the big toe — a possible first-line indication when conservative treatment is poorly tolerated.
indication
Heel pain
Heel pain resistant to the usual treatments.
indication
Plantar or Achilles tendinitis
FHL tenosynovitis and tendon overload perpetuated by the blocked gliding.
indication
Tibial periostitis
Pain along the inner edge of the tibia promoted by impaired push-off.
indication
Painful knee syndromes
Patellofemoral pain syndrome and iliotibial band syndrome, whose origin traces back to the tendon impingement.
Hallux valgus: FHL as the primum movens
For certain diagnoses, FHL tendon release is offered systematically. This is the case in the treatment of hallux valgus, because FHL is regarded as the primum movens of the deformity. The risk of recurrence and the poor reputation of corrective operations for this deformity are partly explained by the lack of awareness of FHL.
It is only a short step to saying the same of the residual laxity frequently observed after anterior cruciate ligament reconstruction — a step not quite taken yet, despite the systematic association of FHL with this type of injury in non-contact trauma.
Surgery that opens the way, not a cure-all
Surgery in itself is not a cure-all: treatment often includes therapeutic follow-up in physiotherapy to correct poor postural habits. The value of this surgery is that it provides 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. The additional prescription of foot orthoses is sometimes beneficial, particularly for rebalancing the load on the forefoot.
Key points
The indication is not based on an image or an isolated symptom, but on understanding the overall mechanical disorder caused by FHL. This is why pain far from the foot — knee, pelvis, back — can fall within the scope of this surgery.
Understanding through video
The experience report presented by Dr Vallotton at the FHL Study Group 2015, covering more than 500 operated cases.
2015 Congress — Surgical experience with more than 500 cases
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The surgical technique
Two incisions, a high-definition camera, under an hour: the endoscopic tenolysis step by step.
At a glance
Typical case
after failed conservative care
First-line option
painful hallux rigidus
Main targets
foot and knee
Hallux valgus
systematic release
Follow-up
often physiotherapy
Adjuncts
sometimes foot orthoses