Home Functional Hallux Limitus Conservative treatment Physiotherapy
Conservative treatment
Physiotherapy, the cornerstone of treatment
Physiotherapy management of FHL begins with a detailed assessment, then combines local treatment of the tendon, foot, and ankle with global postural rebalancing. The patient’s motivation to practice their exercises between sessions is decisive.
Treatments
The functional assessment, a prerequisite to any treatment
Before any treatment, the physiotherapist carries out a detailed assessment. They analyze posture, gait, and balance, along with joint function, muscle testing, and the pain presentation. It is through this assessment that the compensation mechanisms and overloads resulting from unilateral or bilateral FHL are understood. Osteopaths have drawn attention to a frequent blockage of the thoracolumbar junction in this context.
Management follows from these observations, supplemented by the sports and socio-occupational history as well as any medical and surgical history. For the treatment to bear fruit, the patient receives a detailed program so they can practice their exercises themselves between sessions.
Step 1
Initial functional assessment
- Posture, gait, balance
- Joint function, muscle testing, pain
- Sports and socio-occupational history
Step 2
Local treatment
- Hoover cord maneuver
- Selective tendon stretching
- Guided stretching exercises at home
Step 3
Comprehensive management
- Muscle and capsular rebalancing
- Hip flexibility work
- Treatment of associated muscle tightness
Step 4
Progress evaluation
- Six sessions on average
- Analysis of recovery capacity
- Surgical referral if blockage persists
Local treatment, freeing the gliding of the tendon
Once the diagnosis of FHL has been established, the gliding of the flexor hallucis longus tendon must be freed using the so-called Hoover cord maneuver: the subtalar joint is mobilized first, followed by selective stretching exercises on the tendon.
These stretches can be performed lying on the back with the knee extended, but also lying face down with the knee bent, using body weight to dorsiflex the ankle while pushing the toe into extension. The patient then learns to do the exercises themselves by pressing the forefoot against a wall while simultaneously bending the knee to put the tendon under tension. Care must be taken to avoid any pronation or supination movement during these positions.
Signature maneuver
The Hoover cord maneuver
Like a vacuum cleaner cord stuck under a table leg, pulling on the tendon along its axis is useless: the angle of traction must be changed to free it. The maneuver, developed at the Centre du pied, releases the blockage by traction along the axis of the calcaneus with progressive shearing movements. Once the tendon is freed, the stretch test becomes negative and stretching finally becomes effective.
Seminal article
Functional Hallux Limitus or Rigidus Caused by a Tenodesis Effect at the Retrotalar Pulley — Description of the Functional Stretch Test and the Hoover Cord Maneuver
Vallotton J., Echeverri S., Dobbelaere-Nicolas V., 2010, Journal of the American Podiatric Medical Association, vol. 100, no. 3, pp. 220–229.
Examining the foot as a whole
The examination focuses in particular on the path of the flexor hallucis longus at the level of the sesamoids. Early hallux valgus deformity or sesamoid subluxation is indeed often associated with FHL: the sesamoid sling then needs to be recentered using hooking maneuvers, either manual or instrument-assisted.
Pain also frequently appears in the midfoot, due to the excess load placed on the first ray. Mobilization of the Lisfranc or Chopart joints can prove useful to restore mobility to the foot as a whole.
The ankle and the muscles of the foot
The ankle deserves particular attention: the tenodesis effect on the flexor hallucis longus pushes the talus forward into anterolateral subluxation. Reseating the talus posteriorly is beneficial and can be consolidated by stretching the triceps surae.
On the proprioceptive and muscular level, atrophy of the short muscles of the foot is frequently observed, along with hypertonia of the long flexors and the peroneus longus. To counter this tendency, strengthening exercises target the short flexors, and playful “foot mimics” are encouraged. Small foam pads help with muscle strengthening and proprioceptive control while standing on one foot.
Footwear advice
Avoid poor positioning habits such as calcaneal varus, encourage barefoot walking whenever possible, and in all cases strictly avoid wearing flip-flops, clogs, or Crocs.
Comprehensive management, resynchronizing the whole body
FHL causes desynchronization and a change in postural attitude: forward projection of the upper body, increased lumbar lordosis, and an increased flexion moment at the hip and knee. Anterior pelvic tilt bypasses the action of the gluteus medius, shifting the load onto the piriformis muscle, which is often shortened and tight from excessive demands.
Comprehensive management combines muscular rebalancing through selective stretching of the most shortened structures with capsular loosening of restricted joints, the hip in particular. The proximal tibiofibular joint is often stiffened and the popliteus muscle tight from the constant compensation mechanisms.
During the first sessions, treatment focuses on the foot and lumbopelvic statics. Dynamic balance is then strengthened through drills such as backward walking or bounding strides.
Assessing progress
In general, about six sessions are needed to perceive a tangible improvement in pain, whether located in the lower limb or the spine. If the blockage of tendon gliding persists, recovery capacity is analyzed before possibly referring the patient to the surgeon.
In addition, fitting calcaneal stirrups can support physiotherapy treatment, as can osteopathy, which often proves complementary.
The rehabilitation protocol
The detailed exercise program given to the patient is available for download. It serves as a guide between sessions, at home.
Document
FHL rehabilitation protocol
Centre du pied — exercise program given to the patient
Understanding through video
The practical workshop dedicated to physiotherapy and osteopathy for FHL, filmed at the 2016 FHL Workshops.
2016 FHL Workshops — Physiotherapy and osteopathy workshop
Next pillar
Abdomino-lumbo-pelvic core strengthening
Stabilizing the body’s central block to restore the posture destabilized by FHL.
In practice
First-line option
yes
Initial assessment
systematic
Sessions for results
6 on average
Home exercises
daily
Adjuncts
osteopathy, stirrups
Coverage
LAMal
Going further
Related pages
Mobility assessment
The essential preliminary evaluation for calibrating conservative treatment.