Working Diagnosis:
Non-traumatic flexor hallicus longus tendon rupture at IP joint

Treatment:
Encouraged patient to wear shoes for support even when at home. She finished her senior cross country season without difficulty. At this point she was having no pain in her foot or toe and in fact her arch and calf pain has improved with her work with the physical therapist. Given the chronicity of the injury at this time the decision was made to not operate.

Outcome:
Patient remained pain free and on last visit was training for the outdoor track season without any complaints.

Author's Comments:
Closed rupture of FHL tendon is relatively rare with only 35 reported cases in the literature. All 35 of these cases had been associated with an identifiable traumatic event. Three of these cases had occurred in distance runners and two of these patients had prodromal plantar foot pain. Our patient had only calf pain prior to her injury and was not certain of any specific event or time at which the injury had occurred.

The gold standard for FHL rupture confirmation is with MRI, but in this case we did an initial screen with ultrasound which confirmed our diagnosis.

Of 35 reported FHL closed traumatic rupture cases, all were managed with surgical repair. In our patient conservative non-operative management did not limit her functional or athletic abilities and surgical intervention at this chronic point was deemed more risky than beneficial.

Editor's Comments:
This is a unique case as FHL tendon ruptures are rare. It demonstrates the utility of sports ultrasound for to help confirm diagnoses and allow for more certainty in treating athletes prior to more advanced imaging being obtained.

References:
1. Coghlan, B. A., and N. M.p. Clarke. "Traumatic Rupture of the Flexor Hallucis Longus Tendon in a Marathon Runner." The American Journal of Sports Medicine 21.4 (1993): 617-18. Web.
2. Holt, K. W.g., and M. J. Cross. "Isolated Rupture of the Flexor Hallucis Longus Tendon: A Case Report." The American Journal of Sports Medicine 18.6 (1990): 645-46. Print.
3. Lohrer, Heinz, and Tanja Nauck. "Subcutaneous Extensor Hallucis Longus Tendon Rupture: Case Report and Literature Review." Foot Ankle Int Foot & Ankle International 33.10 (2012): 905-11. Print.
4. Romash, Michael M. "Closed Rupture of the Flexor Hallucis Longus Tendon in a Long Distance Runner: Report of a Case and Review of the Literature." Foot Ankle Int Foot & Ankle International 15.8 (1994): 433-36. Print.

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