Tibialis posterior tendon entrapment in posterior malleolar and pilon injuries of the ankle: a retrospective analysis.

BACKGROUND: The Tibialis Posterior tendon (TPT) is the only tendon to encounter the distal tibia and is therefore at greatest risk of injury in fractures of the distal tibia. Although TPT injury has been reported rarely with injuries around the ankle, they often have been missed and present late. AIM: Our aim was to analyse the rate to TPT entrapment in fractures involving the posterior tibia, i.e. Pilon (PLM) and posterior malleolar fractures (PMF). METHODS: A retrospective analysis of PMF and Pilon fractures over an 8-year period was undertaken. Patients who had undergone surgical fixation of their PMF or PLM were identified from 2014 to 2022, using our prospectively collected database. Any fracture which had undergone a preoperative CT was included. Analysis of their pre-operative CT imaging was utilised to identify TPT entrapment, where if < 50% of the tendon cross section was present in the fracture site, this was denoted as a minor entrapment and if ≥ 50% of the tendon was present in the fracture site was denoted as major. RESULTS: A total of 363 patients were identified for further analysis, 220 who had a PMF and 143 with PLM injury. The incidence of TPT entrapment was 22% (n = 79) with 64 minor and 15 major entrapments. If the fracture line entered the TPT sheath, there was a 45% rate (72/172) of entrapment as compared to 3.7% (7/190) in fractures not entering the sheath (p < .001). There was no significant difference in TPT entrapment in PMF as compared to PML (p = 0.353). CONCLUSION: In our assessment, we found significant prevalence of 22% of TPT entrapment in fractures involving the posterior tibia. PMF and PLF had no statistically significant difference in the rate of TPT entrapment. Additionally, we found that there was a significant risk of TPT entrapment when the CT images display the fracture line entering the tendon sheath. We recommend that surgeons consider taking care assessing pre-operative imaging to seek to identify the TPT and to assess intraoperatively where entrapment does occur.

What Patient-related Factors are Associated with an Increased Risk of Surgery in Patients with Stenosing Tenosynovitis? A Prospective Study.

BACKGROUND: Numerous patient-related risk factors have been identified as contributors to patient progression to operative treatment of stenosing tenosynovitis (STS). Identifying patients most at risk of undergoing surgery after receiving a corticosteroid injection would enable health care providers to identify patients most likely to benefit from nonsurgical treatment. QUESTIONS/PURPOSES: (1) What proportion of prospectively enrolled patients with a new diagnosis of STS did not require further intervention after a first, second, or third injection when offered up to three corticosteroid injections? (2) Which identifiable risk factors present at the initial evaluation in patients with STS are associated with the patient opting for surgical release after a trial of one, two, or three corticosteroid injections? METHODS: One hundred ninety-six patients with a presumed diagnosis of STS were evaluated between March 2014 and June 2015, and 160 patients with 186 affected fingers were prospectively enrolled after a new diagnosis of STS was made during the study period. STS was diagnosed by assessing for tenderness at the A1 pulley, passive or active triggering, and the absence of other confounding diagnoses. Only the affected finger received a corticosteroid injection, and these patients were followed up during the study period. Patients were followed for 2 years, and 135 of the 160 patients (84%) completed the final followup. Patients with recurrent symptoms were treated with up to three corticosteroid injections before undergoing A1 pulley release, although patients could elect to undergo surgery at any time. Bivariate comparisons and a multivariate logistic regression analysis were used for independent fingers (one per participant) to identify independent variables associated with progression to surgery after injection. The time between treatments (between injection and subsequent injection or between injection and surgery) for those with recurrent symptoms was also calculated. Information collected from the last time the patient could be contacted was carried forward in the analysis for all 160 patients. RESULTS: No further treatment was sought after the first, second, and third injections by 81 of 160 (51%), 16 of 45 (37%), and three of 10 patients (30%), respectively; 100 of 160 patients (63%) did not pursue further intervention. After the first, second, and third injections, 36 of 160 patients (23%), 17 of 43 patients (40%), and seven of 10 of patients, respectively, did not respond to treatment. After controlling for 21 potentially confounding patient- and disease-related variables, we found that only two risk factors at the initial presentation were protective against eventual progression to surgery: osteoarthritis in the fingers (odds ratio [OR], 0.26 [95% CI, 0.085-0.786]; p = 0.017) and a longer duration of symptoms (OR, 0.58 [95% CI, 0.38-0.89]; p = 0.012). There was no association between progression to surgery and hand dominance, finger type (thumb or other), whether the patient had diabetes, or whether the affected finger was one of multiple affected fingers. Patients who presented again for intervention (injection or surgery) did so at a mean of 153 ± 94 days. CONCLUSIONS: Although patients should be counseled that their risk of progressing to surgery after an initial corticosteroid injection is lower than for subsequently administered injections for recurrent symptoms, nonoperative treatment should not be bypassed for patients with any of the studied risk factors. LEVEL OF EVIDENCE: Level II, therapeutic study.

Bilateral snapping biceps femoris tendon: a case report and review of the literature.

Snapping biceps femoris tendon is an uncommon cause of lateral knee pain. We report the case of a 15-year-old athlete with bilateral snapping biceps femoris tendons, painful over his right lateral leg during exercise. He underwent elective exploration of the right knee which revealed an accessory biceps femoris tendon with attachment to the anterolateral tibia. The accessory tendon was released and reinserted onto the fibular head with a Krackow suture. There were no perioperative complications, and he returned to full sporting activities within 3 months. We describe the operative technique used and summarise the existing literature. Restoring the anatomy with release of the accessory tendon and reinsertion onto the fibular head is an effective technique in the management of knee pain due to snapping biceps femoris tendon. Other approaches include simple release of the anomalous tendon without reinsertion or partial resection of the fibular head. Partial resection of the fibular head is the only technique described in the literature with complication requiring a further operation on the same site. There remains a paucity of evidence in the literature regarding long-term outcomes required to inform the best operative approach. Further anatomical, intraoperative and radiological studies are required to delineate the true pathology of this condition.

Hallux saltans due to stenosing tenosynovitis of flexor hallucis longus: dynamic sonography and arthroscopic findings.

Triggering of the toes is rare, with isolated cases reported in the literature involving predominantly the flexor hallucis longus (FHL) tendon, a condition known as "hallux saltans" (HS). We report the dynamic sonographic findings of a 42-year-old female with a 2-month history of ankle pain and triggering of right hallux, consistent with HS. Sonography demonstrated tenosynovitis and focal thickening of FHL at the level of hindfoot, with a fibrous band adjacent to the tendon. Dynamic ultrasound showed triggering and snapping of FHL tendon during hallux flexion and extension, respectively. We present comprehensive documentation of this rare entity, including sonographic still images and cine clips, as well as correlation with arthroscopic surgical findings.

Case Report: Irreducible Ankle Fracture With Posterior Tibialis Tendon and Retinaculum, Deltoid Ligament, and Anteromedial Joint Capsule Entrapment.

Irreducible ankle fractures are a relatively rare phenomenon. We present a case of a pronation abduction-type ankle fracture that was irreducible in the emergency room despite sedation. The patient was taken to the operating room, where the posterior tibialis tendon and retinaculum, deltoid ligament, and anteromedial capsule were found to be trapped within the joint. After removal of the tissue, alignment was restored. The patient did well clinically and was advanced to full weightbearing at 6 weeks. This is, to the best of our knowledge, the first report of entrapment of all 4 anatomic structures, preventing closed reduction.

Low-Energy Hawkins Type III Talar Neck Fracture-Dislocation With Neurovascular and Tendon Entrapment in a Pediatric Patient.

Several serious complications can occur after talar neck fractures. However, these fractures are extremely rare in children. We present a pediatric low-energy Hawkins type III fracture-dislocation that had excessive displacement accompanied by neurovascular and tendon entrapment. A 9-year-old male patient referred to our hospital 5 hours after jumping off a swing in a children's playground. An excessively displaced talar neck fracture-dislocation was observed at the initial evaluation. The patient underwent urgent surgery. The tibialis posterior flexor digitorum longus tendons, posterior tibial artery, and tibial nerve were entrapped at the fracture site. The talar neck fracture was reduced using open reduction. The neurovascular structures and tendons were removed from the fracture site. The fracture was fixed using two 4.5-mm cannulated screws. The patient was able to bear full weight at 10 weeks postoperatively. At 6 months, the patient was able to walk unassisted with full ankle range of motion. However, at 2 years, his American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score had decreased to 72 points, and we observed avascular necrosis in the talar head. In conclusion, talar fractures are rare but can lead to serious complications. In the pediatric population, even low-energy trauma, such as had occurred in our patient, can result in severe displaced fracture-dislocations. After severe displaced fracture-dislocations, important soft tissue structures can become entrapped between fracture fragments, and surgeons should be aware of this situation when considering using closed reduction.

Incarceration of the Posterior Tibial Tendon in an Isolated Comminuted Medial Malleolus Fracture.

Isolated medial malleolar fractures are a less common presentation of an ankle fracture. Treatment is not universally accepted, although many have agreed that any displacement warrants anatomic reduction and fixation. We present a case of an isolated, comminuted medial malleolar fracture that was displaced secondary to entrapment of the posterior tibial tendon between the fracture fragments requiring surgical intervention. The patient was treated with prompt open reduction and internal fixation and had an excellent functional outcome at 1 year. When open reduction and internal fixation of the medial malleolus is indicated, a thorough exploration of the zone of injury is required to identify and adequately address any surrounding pathologic features beyond just the disrupted bony anatomy. To the best of our knowledge, this specific injury has never been previously reported and emphasizes the importance of understanding the local anatomy and how restoration of the distorted anatomy is vital to optimize patient function.

The anatomy of the fibrous and osseous components of the first extensor compartment of the wrist: a cadaveric study.

PURPOSE: De Quervain disease is the stenosing tenosynovitis of the first extensor compartment of the wrist. It is diagnosed with a history of pain at the radial aspect of the wrist and a positive Finkelstein test. Although anatomic variations, such as a septum within the compartment, are considered as risk factors, bony anatomy of distal radius and its correlation with the septa are studied scarcely in the literature. METHODS: We dissected 50 wrists of 26 cadavers. Presence and location of a septum within the compartment was evaluated. We also observed the grooves at distal radius and their relation to the first extensor compartment and its content. RESULTS: The septum was absent in 23 wrists (46%). A septum was present in 27 (54%) wrists (15 incomplete 30%, 12 complete 24%). At the distal radius, we classified three radial groove types as Type 1 on 28 (56%), Type 2 on 14 (28%), and as Type 3 on 8 (16%) wrists. There was a statistically significant relation between complete type of septa and Type 1 grooves (p = 0.002). CONCLUSION: We investigated the bony structures of the compartment along with its content and we believe our results might guide clinicians who diagnose and treat de Quervain tenosynovitis.

[Aggravated reduction of the posterior malleolar fracture due to incarceration of the flexor digitorum longus tendon]. / Repositionshindernis des hinteren Volkmann-Dreiecks durch Interposition der Sehne des M. flexor digitorum longus.

The indications for stabilization of the posterior malleolus (Volkmann triangle) while fixing ankle fractures are controversially discussed. Detailed descriptions of possible obstacles to reduction are scarce. The following case describes the difficulty of reduction of the posterior malleolus caused by interposition of the flexor digitorum longus tendon. The fracture line of the posterior malleolus passed in an atypical manner vertically to the posterior-medial tibial margin with direct contact to the anatomical pathway of the tendon. The impaction of the tendon was already present in the computed tomography (CT) scan taken preoperatively but the tendon hindering malleolar reduction was first realized during surgery after several unsuccessful attempts at repositioning.

Posterior tibial tendon entrapment within an intact ankle mortise: a case report.

The present case report demonstrates a rare finding associated with irreducible ankle fracture dislocations. To our knowledge, posterior tibial tendon entrapment with an intact ankle mortise has not yet been documented in published studies. In the case of our patient, a high-energy, 12-ft fall resulted in a comminuted intra-articular fracture of the medial malleolus, confirmed by the initial radiographs. Preoperative magnetic resonance imaging showed the Achilles tendon to be ruptured and the posterior tibial tendon to be both displaced and entrapped between the medial malleolar fracture fragments, preventing initial closed reduction. At operative repair for the ruptured Achilles tendon and the medial malleolus fracture, the posterior tibial tendon was removed from the fracture site and was found to be intact with no evidence of laceration or rupture. The tendon was returned back to its anatomic position, and the tendon sheath was reapproximated. Although uncommon, it is important that entrapment of the posterior tibial tendon be considered in cases of irreducible ankle fracture. This injury type can be addressed during open reduction internal fixation to achieve reduction.

Small longitudinal S incision and page turning style of annular ligament partial resection to treat stenosing tenosynovitis of thumb flexor tendon.

BACKGROUND: To present the treatment outcome for patients with stenosing tenosynovitis of thumb flexor tendon treated with a small S incision and page turning style of annular ligament partial resection. MATERIAL AND METHODS: During a 2-year period between August 2011 and July 2013, 12 consecutive patients (mean age, 45.8 years) with stenosing tenosynovitis of the thumb flexor tendon were prospectively enrolled into this study. All 12 patients underwent longitudinal S skin incision to expose annular ligament and thumb flexor tendon, and with page turning style of annular ligament partial resection to finish the operation. The average range of motion of metacarpophalangeal thumb joint, Quick disability of arm, shoulder, and hand and Short Musculoskeletal Function Assessment Dysfunction score of arm and hand were primary outcome measures. RESULTS: There were 9 cases of stiff metacarpophalangeal joint of thumb and 3 cases of snapping thumb for stenosing tenosynovitis. At 1-year follow-up, all stenosing tenosynovitis had healed by an average of 4 weeks. The average range of motion of the metacarpophalangeal joint was 37.1° (range, 34-40°). No patients had recurrence, cicatricial contraction, or postoperative infection. The average disability of arm, shoulder, and hand was 0.3 out of 100 (range, 0-1.67), and average Short Musculoskeletal Functional Assessment Dysfunction score of arm and hand was 6.9 out of 40 (range, 0-15.6). All 12 patients stated that they were highly satisfied. CONCLUSIONS: Small S incision and page turning style of annular ligament partial resection for stenosing tenosynovitis of thumb flexor tendon is a safe, simple, and reliable alternative treatment with minimal soft-tissue irritation, good functional results and recovery can be expected.

Central compartment release versus lesser trochanter release of the iliopsoas tendon for the treatment of internal snapping hip: a comparative study.

PURPOSE: To evaluate the results of 2 different techniques of endoscopic iliopsoas tendon release in the treatment of internal snapping hip syndrome. METHODS: Between January 2008 and January 2012, a consecutive series of patients with the diagnosis of internal snapping hip syndrome were treated with endoscopic release of the iliopsoas tendon. The patients were divided into 2 groups according to the surgical technique used. Group 1 was treated with endoscopic iliopsoas tendon release at the lesser trochanter, and group 2 was treated with iliopsoas release from the central compartment. Hip arthroscopy of both the central and peripheral compartments was performed in both groups by the lateral approach. Associated injuries were identified and treated arthroscopically. The postoperative physical therapy protocol was the same for both groups. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were evaluated preoperatively and at last follow-up at a minimum of 24 months. RESULTS: Twenty patients were included in the study: 6 in group 1 (4 male and 2 female patients; mean age, 35.6 years) and 14 in group 2 (5 male and 9 female patients; mean age, 32.7 years). Associated injuries were found and treated in 4 patients in group 1 and 10 patients in group 2. Every patient in both groups had an improvement in the WOMAC score. One patient in group 2 presented with recurrence of snapping that required surgical intervention. No complications were seen. CONCLUSIONS: Both central compartment release and release at the lesser trochanter produced favorable results, based on WOMAC scores, for the treatment of internal snapping hip syndrome. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Results of labral-level arthroscopic iliopsoas tenotomies for the treatment of labral impingement.

PURPOSE: To document the clinical results of arthroscopic iliopsoas tenotomies performed at the level of the labrum to treat labral injuries caused by iliopsoas impingement. METHODS: From a review of the database of the senior author (J.S.K.) of 300 hip arthroscopies that were performed between September 2009 and May 2011, 30 patients who had an arthroscopic release of the iliopsoas tendon at the level of the labrum and at least 2 years' follow-up were identified. In all cases the release was performed to treat a tight psoas tendon that was found at arthroscopy to be impinging on a torn or inflamed labrum. The results of hip arthroscopy in these patients were assessed with Byrd's 100-point modified Harris Hip Score system before arthroscopy and at 3, 6, 12, and 24 months after surgery. RESULTS: The mean age of the 30 patients was 35 years, and their preoperative scores averaged 43 points. After surgery, the patients had 6-month scores that averaged 73 points and 12-month scores that averaged 84 points (range, 40 to 100 points). Over the first postoperative year, in 3 of the 5 patients whose preoperative ultrasound imaging showed snapping of the tendon, recurrent painful snapping developed in the hip. All 3 had iliopsoas bursa injections and had immediate relief of their hip pain. In 2 patients the relief was temporary and an arthroscopic release of the tendon at the lesser trochanter was performed. The 2-year scores of the remaining 28 patients who did not have a second iliopsoas tenotomy averaged 88 points, and 23 of these patients had good or excellent results (scores ≥80 points). CONCLUSIONS: An arthroscopic release of the iliopsoas tendon at the level of the labrum was effective for alleviating hip pain from labral lesions caused by impingement of the tendon in 23 of 30 patients (77%). The remaining 7 patients had persistent hip pain and hip scores lower than 80 points because of recurrent snapping of the tendon (3), development of avascular necrosis (1), progression of degenerative joint disease (1), or chronic greater trochanteric bursitis (2). LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Treatment of Chronic Extensor Carpi Ulnaris Stenosing Tenosynovitis Using Ultrasound-Guided Retinaculum Release: A Case Report.

CASE: A 65-year-old man with chronic extensor carpi ulnaris (ECU) stenosing tenosynovitis who had failed treatments for 3 years was successfully treated with an ultrasound-guided retinaculum release of the sixth dorsal compartment. CONCLUSION: There are limited options in the literature for treating chronic, recalcitrant ECU tenosynovitis. We describe a novel technique in which the retinaculum overlying the ECU tendon was successfully incised under ultrasound guidance to release the sixth dorsal compartment stenosis. There was no recurrence of symptoms in the following 2 years of follow-up.

Histopathological characteristics of stenosing flexor tenosynovitis in diabetic patients and possible associations with diabetes-related variables.

PURPOSE: To compare the histopathological findings of stenosing flexor tenosynovitis (SFTS) in diabetic patients with those in nondiabetic patients and to analyze the predominant characteristics of SFTS in diabetic patients by statistical methods. METHODS: We included 63 patients (63 specimens) who underwent excision of A1 pulleys for SFTS. A total of 38 patients (38 digits) were diabetic and 25 (25 digits) were nondiabetic. We obtained specimens from the proximal one-third of each A1 pulley and analyzed them by histological and immunohistochemical methods. After we identified the predominant histopathological characteristics of SFTS in patients with diabetes, we performed multiple logistic regression analysis to examine the possible associations between the histopathological characteristics and diabetes-related variables. RESULTS: We divided histopathological findings into 3 types in both diabetic and nondiabetic groups. Types 1 and 2 showed fibrocartilage metaplasia including fibrocartilage-like cells surrounded by basophilic extracellular substances. Type 2 was characterized by the presence of granulation tissue in the middle layer, which was not recognized in type 1. The granulation tissue contained newly formed microvessels, stromal cells, a small number of inflammatory cells, and extracellular matrix that showed myxomatous degeneration. Type 3 showed a decrease in fibrocartilage-like cells with surrounding extracellular eosinophilic substances, which was similar to hyaline degeneration. The histopathological features of type 2 were found in 68% of the diabetic group and in 28% of the nondiabetic group. This difference was statistically significant. The findings of type 2 were significantly associated with the severity of diabetic retinopathy and hemoglobin A1c values in the diabetic group. CONCLUSIONS: Type 2 findings were more frequent in the diabetic group than in the nondiabetic group. A pathomechanism to accelerate neovascularization and hypercellularity in the granulation tissue in the middle layer of A1 pulley may exist, especially in diabetic patients with severe retinopathy and poorly controlled hyperglycemia.

[Arthroscopic transcapsular iliopsoas tenotomy from the peripheral versus the central compartment in internal snapping hip syndrome. Short-term results of a prospective randomised study]. / Artroskopická transkapsulární tenotomie iliopsoatu u vnitrního typu syndromu lupavé kycle z periferního versus centrálního kompartementu: krátkodobé výsledky prospektivní randomizované studie.

PURPOSE OF THE STUDY: In this prospective randomised study, the short-term results of arthroscopic transcapsular iliopsoas tenotomy approached from the peripheral versus the central compartment for internal snapping hip syndrome are presented. MATERIAL AND METHODS: A group of 19 patients (15 women and four men; mean age, 24.3 years) who underwent arthroscopic transcapsular iliopsoas tenotomy for internal snapping hip syndrome in the period between September 2010 and December 2011 were prospectively evaluated. No injury, hip surgery or feeling of hip instability was recorded in their personal histories. Radiographs did not show any dysplasia, retroversion of the acetabulum or cam lesions. The patients were allocated to two groups using sealed envelope randomisation: Group 1 patients (n=10) were treated by tenotomy from the peripheral compartment and group 2 patients (n=9) underwent tenotomy from the central compartment during traction of the lower extremity. The evaluation included pre-operative 3T MRI findings, arthroscopically detected intra-articular lesions, duration of traction and post-operative complications. The pre-operative WOMAC scores were compared with those at one-year follow-up. In comparison of the two groups, the Mann-Whitney exact test was used for WOMAC scores and Fisher's exact test for post-operative complications. Statistical significance was set at a 0.05 level. RESULTS: In comparing post-operative complications, a significant difference (p=0.0468) between the groups was found only for genital paresthesia, which did not occur in group 1. The other differences were not statistically significant. The pre-operative WOMAC scores did not differ significantly between the groups (p=0.79). The post-operative WOMAC scores were significantly higher in group 1 (p=0.02). In each group the change in WOMAC scores was different and was statistically significant in group 1 (p=0.0014). Associated intra-articular hip pathologies, most frequently synovitis of the peripheral compartment, acetabular chondropathy, or labral lesions, were diagnosed in 90% of group 1 patients and in 66.7% of group 2 patients. DISCUSSION: Most of the authors comparing the results of two different ilioproas tenotomy techniques at one-year follow-up did not report any statistically significant differences in WOMAC scores between them. In accordance with the data reported, an increase in the post-operative WOMAC score, i.e., improvement of clinical outcome, was achieved in all our patients and, in group 1, it was significantly higher (p=0.0015), as compared with a similar study by Ilizaliturri. However, further follow-up of the patients and evaluation of long-term results will be necessary. CONCLUSIONS: The technique of arthroscopic ilioproas tenotomy approached from the peripheral compartment resulted in significantly fewer cases of genital paresthesia and provided significantly better clinical outcomes in comparison with tenotomy from the central compartment.

Irreducible Ankle Fracture Dislocation Because of Tibialis Posterior and Flexor Digitorum Longus Tendon Entrapment in the Interosseous Membrane: A Case Report.

CASE: We describe the case of a 63-year-old man with anterior ankle dislocation and fracture confirmed by x-ray. Postreduction x-ray and computed tomography (CT) revealed Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 44C3 and Lauge-Hansen pronation-external rotation-type ankle fractures. CONCLUSION: This was a rare case of ankle fracture dislocation because of entrapment of the tibialis posterior and flexor digitorum longus tendons in the interosseous membrane. Tendon entrapment should be suspected in cases of high-energy injuries, Weber type C fractures, Lauge-Hansen pronation-external rotation fractures, syndesmosis widening, and irreducible fractures using manual closed reduction. Fractures and soft tissues should be evaluated by changing the CT settings.

Labral injuries due to iliopsoas impingement: can they be diagnosed on MR arthrography?

OBJECTIVE: Iliopsoas impingement is a new arthroscopic diagnosis that refers to an anterior labral injury caused by the iliopsoas tendon. Currently, there are no preoperative criteria to establish the diagnosis of iliopsoas impingement. The goal of this study was to determine whether there are imaging criteria that would identify iliopsoas impingement on preoperative MR arthrography. MATERIALS AND METHODS: This study compared the preoperative MR arthrograms of 23 patients who had iliopsoas impingement diagnosed at hip arthroscopy with the arthrograms of 24 patients who did not have iliopsoas impingement found at hip arthroscopy. All of the arthroscopies were performed by a single orthopedic hip surgeon. In all cases of impingement, there was an isolated injury to the labrum at the 3-o'clock position. All were treated by arthroscopic iliopsoas tenotomy performed at the labral level. The MR examinations of the 47 patients were evaluated independently by two musculoskeletal radiologists who were blinded to the diagnosis. The following characteristics of the iliopsoas tendon at the level of the anterior labrum were evaluated: lateral dip, increased signal intensity (SI) between the iliopsoas tendon and labrum, irregularity of the deep margin of the iliopsoas tendon, edema within the iliopsoas tendon or capsule at the 3-o'clock position, presence of a labral tear at the 3-o'clock position, dimensions of the iliopsoas tendon, and location of iliopsoas tendon as it passed the labrum. Statistical analysis was performed using the Kruskal Wallis test, Fisher exact test, and Cohen kappa. Values for p less than 0.05 were considered significant. RESULTS: Nineteen women (mean age, 35 years) and four men (mean age, 36 years) had central iliopsoas impingement. Sixteen women (mean age, 38 years) and eight men (mean age, 35 years) did not have central iliopsoas impingement (p=0.318). For the impingement and nonimpingement groups, lateral dip of the iliopsoas tendon was seen in 15 of 23 (65%) and 17 of 24 (71%) for reader 1 and 18 of 23 (78%) and 11 of 24 (46%) for reader 2, respectively (p=0.76 and 0.036, respectively). There was no difference between the groups for increased SI between the iliopsoas tendon and labrum (p=0.38 and 0.82, respectively), irregular deep margin of the iliopsoas tendon (p=0.61 and 0.35, respectively), thickness of the iliopsoas tendon (p=0.33), or tendon or capsule edema (p=0.37 and 0.77, respectively). Reader 1 found 20 of 23 and reader 2 18 of 23 labral tears at the 3-o'clock position in the iliopsoas impingement group, with 13 of 24 and 10 of 24 in the non-iliopsoas impingement group respectively (p=0.024 and 0.017, respectively). The combined iliopsoas tendon width for both readers was 10.2 mm (range, 8.1-14.3 mm) in women and 11.9 mm (range, 11.1-13.4 mm) in men in the iliopsoas impingement group (p=0.0285), and 11.0 mm (range, 9.0-12.6 mm) for women and 11.8 mm (range, 8.7-15.1 mm) for men in the non-iliopsoas impingement group (p=0.159). The iliopsoas tendon most commonly crossed the labrum at the 3-o'clock position in both groups (p=0.83-0.17). CONCLUSION: An acetabular labral tear at the 3-o'clock position should suggest the diagnosis of iliopsoas impingement.

Hallux saltans due to flexor hallucis longus entrapment at a previously unreported site in an unskilled manual laborer: a case report.

Triggering of the big toe, or hallux saltans, is commonly due to stenosing tenosynovitis of the flexor hallucis longus at the fibro-osseous tunnel below the sustentaculum tali. It is a rare condition described mainly in female ballet dancers. This is hypothesized to be due to the en pointe position used in ballet, which puts enormous supraphysiologic loads on the flexor hallucis longus, predisposing it to injury. Trigger hallux is extremely uncommon in the general population. We are reporting a case of hallux saltans in an unskilled manual laborer, with the site of tendon entrapment just proximal to the medial malleolus in the distal leg, a hitherto unreported location of stenosis.